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MANUAL 


MILITARY  SURGERY, 


FOR    THE    USE    OF 


SURGEONS  IN  THE  CONFEDERATE  STATES  ARMY ; 


WITH  AN    APPENDIX  <>F  Till'. 


JtoUs  and  geplations  of  the  vftlcdiral  Department 


CONFEDERATE  STATES  ARMY. 


J.  JULIAN   (  IIISOLM.  M.  D.. 


(.  I  Mi's     :  \    THE   MEHMW  I     i   ,.i    I 
\    |\   7  111     CO.VKEDl   I.  \  i  I'.   STATE8    \RM  V.   i:1 


PUOFESSOn  "F  sn;CKCV   in   the  MEDICAL  I  OLL1  '-i     "I     SOI  TH  CAROLINA, 


137549 


SECO.Mi  ElMTkl.\-l!EUNELl  AMI  IMI'RU\EI>. 


i;i<  EMOND,  VA 

.1  QRVBTQ  N.   Mo    MAIN    BTB  I 

L862. 


;i^  \\ 


i  the  year  l  Si 

.1   J.  OHISOLH,  m  .  D. . 

In  the  i  „rt  of    the  CoufWIoi  ito   State*  bl    lli«. 

'   Cliiirl.Hlon.    -  int. 

.  CaAauwroa 


• 


#42.' 


In  putting  t'orth  tliis  Manual  of  Militan  Surgery  for  the  use 
of  Surgeons  in  tin-  Confederate  service,  1  have  been  led  by  the 
desire  to  mitigate,  it'  possible,  the  horrors  of  war  as  Been  in 
ii-  most  frightful  phase  in  military  hospitals.  A.s  our  entire 
army  is  made  up  of  volunteer*  from  every  walk  of  lite,  ag 
we  find  the  surgical  staff  of  the  army  composed  of  physicians 
without  surgical  experience*  Mosl  of  tlm-e  who  now  compose 
the  surgical  staff  were  genera]  praciitioneis,  whose  country 
circuit  gave  tliein  hut  little  surgery,  and  xrvy  seldom  pre- 
sented a  gunshot  wound.  As  our  country  had  been  enjoying 
an  uninterrupted  Btate  of  peace,  the  collecting  of  large  bodies 
of  men.  and  retaining  them  in  health,  or  the  hygiene  of 
armies,  had  been  a  study  without  an  object,  and.  therefore, 
without  interest  When  the  war  suddenly  broke  upon  us.  fol- 
lowed immediately  by  the  blockading  of  our  ports,  all  commu- 
nication was  cut  off  with  Europe,  which  was  the  expected 
source  of  our  surgical  informatiofj  As  there  had  been  no  pre- 
vious demand  for  works  on  military  surgery,  there  were  none 
to  be  had  in  the  stores,  and  our  physician-  were  compelled  to 
follow  the  army  to  battle  without  instruction!  X  ■  work  on 
military  surgery  eouhl  be  purchased  in  the  Confederate  State-. 
As  military  surgery,  which  is  one  of  expediency, differs  so  much 
from  civil  practice,  the  want  of  proper  information  has  already 
made  itself  seriously  frit.  In  times  of  war.  where  invasion 
threatens,  every  citizen  is  expected  to  do  his  duty  to  his 
I  m»  no  better  means  of  showing  mj  willingness  td  eq 
the  cause  than  by  preparing  a  Manual  of  instruction  for  thi 
the  army,  which  might  be  the  means  of  saving  the  lives 
and    preventing  the    mutilation  of  many   friends  and    country- 

The    present    volume   contains    the    fruit   of   Eur 
experience,  as  dearly  purchased  in  recent   campaigning.      Be- 
sides  embodying   the   experieq  in    military 


137549 


urn  nt   of  wounds,  I   have  incorporated 
■   upon  tli'  ing  anil   hygiene  <>i'  troops;  with 

«  how  the  health  <>t'  an  arm)   i*  i"  be  preserved,  and 
I,,.-,  i  be  sustained  ;   also,  Che  duties 

•■-.  both   in   the  cainp  and    in   the  6eld.      In 
•iii'l   the   regulations  -   lor  the 

.,1  the    M'  'ii  -il   il<-|i-irtm<  lit   of  the   Con  irmy.      In 

in'-.  1  have  n"t  hesitated  t"  add  u<  my  own 
treatment  of  surgical  injuries  anj  useful 
I  ould  obtain  from  the  most  recent  Ger- 
man, French  and  English  works  on  military  surgery  :  and  in 
mani  instances,  where  the  language  used  by  them  expressed 
t.>  tli-  point  the  subjeat  under  discussion,  I  have  not  hesitated 
t  i  transfer  entire  sentences  directly  to  these  pages.  I  make  t!ii> 
acknowledgment  en  >mi-.«  of  the  very  liberal  use  of  the  follow- 
ing works,  as  quotation  mark-  were  sometimes  overlooked: 

men  der  Kriegshcilkunst.  >"ii  I..  Stromyer,  Hanover, 
18*5;  Supplement  tier  Maximeri  Hit  Kriegsheilkunst,  TOfl  L. 
myer,  Hanover,  I860;  Leeffler  BehancHung  der  Schnss- 
wande,  Berlin,  1869;  Histoire  Me*dico-Chirurgicale  de  la  Guerre 
de  t'liiiK-.-.  par  le  docteur  Adohphe  Annaml.  Paris,  1858;  La 
Guerre  de  (rimer,  par  I..  Baodens,  Paris,  1858;    Des  Plaies 

■  i'Arme-  a  leu  :  Couiuiunit-ation-  l-'aite-  a  1 " . \ < • ; i ■  I < •  i n i < •  Nation- 
ale  de  Medicine,  Paris,  1849;  Notes  of  the  Wounded,  from  the 
Muiiin  in  Imlia.  I>\  Cn-u^r  \\'iili,uii-i)ii.  Londooj  UJ59 ;  l  "!<•>' 
Military  Surgery,  with  Experience  "t'  Field  Practice  in  India, 
Load  -  Gunshot    Wounds    of  the    Ghcst,    by    Patrick 

•  I   l».  London,  L859;    Guthrie's  Commentaries  on   Mil- 
London,  1855;   MeLeod*a   Notes  on  the  Surgery 
el"  the   Crimean  War,  London,   1858;    Hcnnen's   Principles  "i 
ft  Militan  Surgery;   Ballingall's  Out- 

i  jj  SJui  •.,-,  j    ;     Ij-ieli- 

\       r  S  -1     kson  on  the  PormatioB, 

I    unotnj  of   (  9    lillot,  Mi  dicinc  ( >pera» 

\    l'  I  "ii    Military   Surgery, 

bj    I"    II    Hamilton,   M    l»     Won    Jfork,  1861;    Report    M.di- 
i1  nt  (Army)  ordered  by  the  House  of  Commons  to 

:  avia  on  Feigned  Diseases,  Lon- 
don, i 

;  h 

4 


^ 


INDEX 


PASS 

Abdominal  wonnds 343 

Acclimation  of  soldiers 2 

Advice  bo  surgeons  left  with  the  enemy 162 

Ape  necessary  to  make  a  soldier 8 

Ambulance  corps 107 

A  in  1  >u  la  n.  :e  cjprpe  in  French  army lt>'.i 

%  Ambulance  wagons W 

A  in  bu  la  n  cc  wagons,  <  Iqnfcderate 93 

Amputation  of  arm 396 

Amputation,  after-treatment  of 131 

A  in i >n  i  :n  i< 'ii.  when  required 122 

■\iii]«uiM!'ons.  rules  for 121 

Amputation,  primary  and  secondary 12". 

A  in  (tii t  a t  i. >n  of  tliijrli,  for  compound  fractures M  0 

A  in  n  sem  cuts  of  soli  Hers 63 

An  i-scorbutics 11 

Appearances  of  gunshot  wounds 163 

.  compound  frai  ture  of 37? 

Arteries,  escape  injury 166 

Arteries,  injury  ol 137 

Arteries,  ligation  of I vs 

Articles  necessarj  i  d  the  field 134 

'Assistant  srfrgcon,  duties  of 127 

adants  in  s  rag  mental  hospital 70 

i  general  hospital 72 

Halls,  how  to  extra*  t  t  In  in * LiM 

MU   • "''•"■ 

Hall.-,  u  In  n  .  io\  -ti  .1  alwa\  -  danger<   .- I  BO 

net   wiiiiol- 

);e.|  of  soldier 

Brvonack  

Bladder  wounds •••'>» 

*2 


I  \  w  \ 

rv.r 

•  '  -  ' 

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l;;- 

' 

lira    ii '• 

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52 

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(             -   W41 

1                                                            W5 





ihijrl •''•' 

1                                             IM 

>                                                  '•'" 

»                                                1<W 

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1                                         Im 

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B6 

88 

186 

led •'! 

1 1 

308 

9^ 

Iter Ill 

Held I.")S 

1 1»7 

IB 

i                                                 127 

•                                                    117 

ii 121 


lNin-.x.  vi  i 

PAQ-B 

Duties  of  a  surgeon  ou   the  battlefield  130 

Dyspnoea  in  chest  wounds 326 

Effects  of  conical  ball L63 

Elbow-joint,  resection  of 393 

Emphysema  in  chest  wounds 327 

Encysted  balls  always  dangerous 180 

Endermic  n*e  .>f  uiorpbinc 223 

English  army,  medical  department   of 195 

Enlistment,  rules  for 14 

Entrance  and  exit  of  balls 185 

Epidemics  in  hospitals 16 

Equipment  of  a  soldier 80 

Erysipelas 228 

Examination  of  wounds LM 

Expo  sure  to  camp   diseases 3 

Exposure  in  the  field,  how  borne  by  different  classes 7 

Extraction  of  balls I*  4 

Face  wounds 309 

Feeding  aid  clothing  of  troops 16 

Reigning  disease 138 

►Female   nurses  in    hospitals 83 

Field  infirmary 140 

Field  surgery,  art teles  used  in 133 

Field  surgery  proper 1  19 

Field  surgery  with  the  t  ran  sports 1  15 

Food  of  soldiers  in  the  Confederate  army ■"••> 

Fording  a  ri\  ulet 40 

d  bodies  to  be  removed 375 

Foreign  bodies  in  brain 304 

Foreign  bodies,  removal  of 177 

Fract  ure,  compound 365 

Fracture  of  bones  of  the  face 312 

Fracture  of  ribs 340 

Fracture  of  skull 205 

Fracture  of  tlii-b 399 

French  medical  siaff 10(6 

French  organization  of  an  ambulance  corps IW 

Fresh  meat  for  i roops •"■ii 

Frost-bite 415 

Fund,  hospital 120 

I  •           in' - 

Q           .1    lei.  -pita! 71 


* 

IM 

IBS 



1  ''•'■' 

98 

I  St 



i  

I  70 

Ml 



H  I  

i .  - 

i1  Ml 

1  ii.! ir- 

I  ft 

H 

II  '■ 7  V. 

7  • 

!  v'» 

117 



J  I  7 

n   "1 77 

II 

248 

mis I  Ml 

batllefleld 1  Hi 

•_':'  I 

I  ->  7 

::  1 1 

3  In 

S 1 1 1 

::s  \ 

i  l. •.(■■ 

41  ii 

i  HI 

86 

I  3Qf] 

I  ss 

I  132 


TNPV.X.  IX 

Litter  carriers 107 

Litters,  horse 96 

Litters,  hand 93 

Local  i  reatmenl  of  wounds 195 

Lower  jaw,  fracture  of 8 1  - 

Lit n _r  wounds 823 

Malingering,  i  r  feigning  disease l.'!S 

March,  net  inn  of  troops  during 17 

Materia]  of  armies 5 

Medical  department  of  Confederate  army HH 

Medical  department  of  SngKsh  army 105 

Medic  'a!  cic  partoraeut  of  French  army 106 

Medical  department  of  Prussian- army 106 

Mc  ,  lion  I  Supplies  "11  the  field I ,".:; 

Mc-<s  ot   I  liicei's  and  privates 46 

Mexican  war  statistics 9 

Morphine,  endennie  use  of 823 

Mortuary  reports  of  Mexican  war . 10 

Xec  k   wounds 818 

Necessity  of  Hygiene 4 

Nervosa  shock ' 155 

Nervous  shock 168 

Object  of  clothing 17 

Opium  in  gunshot  wounds 223 

Orifices  of  entrance  and  exit 1  ii  l 

Pain  in  gunshot  gounde 167 

Pain,  periodic 273 

Peritoneal  inflammation 353 

Permanent  cam] 62 

Physiol....  y  of  clothing 17 

Portable  ten!  of  the  French  troops §5 

Primary  amputation 42o 

Privies f,0 

Probing  ol  wounds 17  1 

Prussian  medical  staff 108 

Punctured  wounds i'l  I 

Pus,  its  character  and  value i'  1 1 

Pus  in  i boras 

Pyemia 238 

fta    ion   in   th     I      :    rate  army 12 

Etccruita 

Recruiting  service,  rules  for IS 


X 



•*' 



:i  l.i.ilir- 177 



i.ip  j-iiit 

1  knee-join  I Ill 

i  : 

Bib*,  i  





i  iiiiinaii'iii  of  reeruiis ' ' 

Sabre  wounds -'  I ' 

I  '•'  i 

try  hemorrhage 

•  i  SMI 

ary  amputatii  dj 428 

-  for  hoanitali ...     M 

mded  n "t  to  be  moved Wl 

•  i  1 1 1 « •  Frenofa  troopa 

i 

Shoulder-joint)  resecl  ion  <>i 

Skull,  fracture  of 

rior  splint* 108 

•  li'-c J 

Soup  foi  37 

Mali-- 1      ■  i   Mexican  war '•' 

Stumps,  li<>«  dressed I-'.' 

Supplies  necessary  on  the  field i  ■  • 

as,  duties  of  in  earn] 121 

;  on  battlefield 130 

u's  haversack 187 

i.-,  hospital  duties  of I » •  7" 

ft  with  the  ironnded Ifil 

i  infirmary 149 

ry  with  the  ti  14<J 

L01 

I 

hanging  of >9 

Rents  for  bospitah 67 

Ti  hi  I.  8 




INUKX. 


PA0I 

Thirst,  how  relieved 40 

Thigh-joint,  resection   of 400 

Thorax,  wounds  of 317 

Tourniquet 171 

Transports  on  the  battlefield 158 

Transportation  of  sick  and  wounded 90 

Transportation  of  the  wounded l.">7 

Treatment  of  abdominal  wounds 346 

Treatment  of  chest  wounds 330 

Treatment  of  compound  fractures .",711 

Treatment  of  concussions 281 

Treatment  of  erysipelas 236 

Treatment  of  head  injuries 288 

Treatment  of  hospital  gangrene 256 

Treatment  of  intestinal  injuries :',  1  I 

Treatment  of  joint  wounds 385 

Treatment  of  gunshot  wound- 169 

Treatment  of  pyaemia 245 

Treatment  of  secondary  hemorrhage 209 

Trephining  not  required 301 

Troops,  when  on  march i7 

Typhus,  care  necessary  to  prevent  spreading 81 

Ides,  as  food  for  troops 40 

Ventilation  of  hospitals 77 

escape  injury Dm', 

Volunteers — of  what  material  composed b 

Wagons,  ambulance BY 

Water  dressings  for  wound- 197 

Water — how  used  when  on  march r.i 

Winter  quarter.-  for  troops 54 

Wire  splints  for  leg 106 

Women  in  hospitals 

Woorars  in  tetanus 269 

Wounded,  transportation  of 91 

Wounds,  appearances  of 163 

Wonndi  on  the  field 159 

Wounds,  examination  of L50 

Wounds,  first  treatment  of 145 

Wonnds,  general  treatment  of 2 16 

Woands,  local  treatment  of In 

Wounds,  punctured 214 

wounds  of  abdomen 


xn  IHMM 

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C  IF  A  P  T  E  R    I. 

Susceptibilities  of  Soldiers — Material  of  Armies — !!•  - 
ermting — Gfathmg — Food — Encampments — AnvUse- 
menfe,  etc. 

As  the  strength  of  an  army  depends  more 
upon  the  health  and  physical  development  of 
the  soldier  than  in  mere  numbers,  the  hygiene 
of  camps  and  the  susceptibility  of  soldiers  to 
disease,  has  long  been  a  worthy  study  for  mili- 
tary leaders.  Wlien  men  are  taken  from  civil 
life,  where  they  are  accustomed  to  think  and  act 
for  themselves,  and  arc  gathered  together  as  sol- 
dier.*, the  very  ftel  of  acknowledgment  or  mus- 
tering in.  deprives  them  of  all  liberty  of  action, 
and  makes  them  dependent  upon  their  superior 
officers.  They  must  now  live  after  a  formula — 
with  it<  drills,  labors,  fatigues,  privations,  expos- 
ares,  guard  duties,  aigbl  watchings  and  rigid 
discipline.  This  new  life,  which  is  so  different 
from  his  former  habits,  establishes  a  new  era. 
similar  to  acclimation,  and  which  is  as  marked 
1 


SI  SCKPTIR]  r   SOLDI Kl 

in    its   effects   upon    the   constitution  of  the  bo!- 
dier. 

This    sudden    change    from   civil    t«>    military 

life,   like   accliniation,  constitutes  ft   physiological 

and    moral    «risi  -.    wliieli    is    evident    in    an    in- 

ascd    mortality,   ae    an    initiation    for    the    t i i  - 1 

eding   \ ears  <>t  service. 

The  physical  and  organic  revolution  which 
this  change  engenders,  establishes  a  special  pa- 
thology for  Boldiers,  which  differs  in  many  re- 
spects from  the  negular  forms  which  are  observed 
in  the  routine  of  civil  practice. 

The    dis(  i    camps    are    few,    and    exhibit 

:i  striking  uniformity  of  character,  dependent 
upon  numerous  depressing  causes,  to  which  all 
soldiers  are  equally  liable,  and  Which  belong  in 
common  to  every  army,  irrespective  of  nation- 
ality and  climate.  Continued  exposure  and 
fatigue,  bad  and  insufficient  food,  suit  meat. 
in  differ  on  1  clothing,  want  of  cleanliness,  pdor 
shelter,  exposure  at  night  to  sudden  chairg 
of  temperature,  infected  tents  and  ctimps,  fiwrm 
a  combination  of  causes  which  explains  the  fatal- 
ity .>t'  an  army  in  the  field. 

I-  ;n  ■■  usually  draw  n  from  the  rural  dis- 
tricts, wher<  thej  have  never  been  expofecd  60 
those    morbific    causes    which    are    incidental    t<> 


NECESSITY    OF    HYlilKM 


B 


the  atmosphere  of  cities,  and  which  entail  a 
series  of  infantile  diseases  upon  the  growing 
generation.  The  unavoidable  exposure  and  the 
general  liability  to  these  causes  whilst  in  transit, 
to  which  city  troops  are  exempt,  make  such  dis- 
eases a  fearful  scourge  in  armies.  The  measles. 
a  mild  disease,  which  excites  no  alarm  under 
ordinary  conditions  of  protection  from  the  wea- 
ther,  strikes  terror  in  a  camp,  where  its  sequela* 
of  pneumonia  and  phthisis  are  truly  fearful. 
This  disease  alone  has  laid  a  heavy  percentage 
upon  the  effective  strength  of  our  army.  Add 
t<>  this  and  kindred  eruptive  diseases,  glandular 
affections,  tuberculosis,  capillary  bronchitis,  ty- 
phoid and  malarial  fevers,  with  diarrleea  ami 
dy-ciitery.  and  we  have  already  summed  up  the 
chief  causes  of  army  mortality  and  deterioration 
of  Strength.  All  of  these  diseases  can,  to  a  cer- 
tain extent,  he  avoided  by  recourse  to  a  proper 
hygiene,  which  1ms  not  been  valued  by  com- 
manding officers,  and  in  many  instances  has 
neither  been  recognized  nor  urged  by  the  health 
officers  of  the  command.  Until  the  claims  of 
hygiene  are  duly  considered,  and  its  necessity 
acknowledged,  the  mortality  will  continue  from 
causes  which  can  readily  he  counteracted* 

Prudence   and    forethought,    which    should    be 


SKCKSSm     OF    IIY',11  M' 


leading  traits  in  the  character  of  a  military  man. 
seldom  enter  into  the  composition  ef  officers  \\1k». 
in  times  of  war.  join  the  army  to  fight,  and  oas> 
aider  all  those  details  so  necessary  to  preserve 
an  effidtent  force  to  light  w'uli.  as  derogatory  t<> 
their  imaginary  official  «luti«-s.  0«r  army  will 
always  be  burdened  irith  heavy  mortuary  lists. 
extensive  hospital  organisations,  a  Large  pay  roll, 
and  comparatively  few  efficient  troops.  /<  'Unless 
officers  take  more  interest  in  the  general  wel- 
fare of  their  men,  and  cease  to  consider  profes- 
sional advice  offensive  and  intrusive. 

As  it  takes  tine  and  a  considerable  outlay  to 
make  a  Boldier,  it  behooves  the  Government  to 
keep  them  in  a  useful  condition,  which  can  only  be 
effected  1 » \  the  unceasing  labors  of  the  medical  stall" 
and  the  rigid  enforcement  of  all  sanitary  regula- 
tions bj  the  commanding  officers.  Among  volun- 
teer troops,  where  the  regulations  of  a  regular 
army  cannot  be  enforced,  it  should  be  the  duty  <>l' 
the  officer  in  command  to  appeal  to  the  good  sense 
of  the  soldier  through  the  orders  of  the  day. 
and  gradually  to  instil  such  wholesome  rules  of 
eue  as  will  make  them  individually  careful 
lor  the  general  good.  The  sick  list  will  offer  a 
fair  criterion  of  the  military  status  of  an  officer 
ami    his    capacity    for    taking   care   of   liis   men. 


MATERIAL    OF    ARMIES.  9 

which    is    one    of   the    first    rules  in   military  sci- 
ence. 

RsOKl  its. — In  times  of  peace  an  army  is 
formed  of  recruits,  who  are  enlisted  with  much 
care.  Eaeh  individual  before  he  is  received  un- 
dergoes a  critical  examination  by  the  recruiting 
medieal  officer,  who  rejects  all  blemishes  as  well 
as  those  conditions  showing  a  predisposition  to 
disease;  the  object  gained  being  the  selection  of 
a  body  of  men  who,  from  physical  and  vital 
perfection  o\'  organization,  will  best  resist  exter- 
nal morbid  influences.  Besides,  they  are  men 
whose  inclinations  lead  them  to  pursue  a  life  to 
which  they  are  in  a  measure  fitted,  by  the 
rough,  exposed  lives  which  such  applieants  have 
previously   led. 

Volixti  i.iis. — In  times  of  war.  especially  be- 
tween contiguous  countries,  where  national  ani- 
mosity rages  high,  entire  communities  rush  to 
arms,  and  with  one  accord  adopt  eamp  life  with 
its  exposures  and  trials.  Among  those  who  take 
up  arms  in  defence  of  their  rights,  or  for  the 
protection  of  their  homes  and  families,  are  found 
men  from  ever)  positm  m  Life — from  those  en- 
joying   the     most    refined    and    cultivated    social 


'  iMAI.    <>t     aio: 

privileges    to    tl  i  laborer  —  all    having    • 

common  cause  to  Bupporl  ;  men  i>t"  every  vari- 
ety of  constitution,  temperament  and  idiosyn- 
orasy,  in  whom  even  form  of  disease  is  found 
Lurking^  an<l  ready  t<>  show  itself  apon  the 
slightest  provocation.     Those  who  have  1  * ' <  1  lives 

-■■  and  luxury  are  suddenly  called  upon  to 
in  1 1n*  stern  and  laborious  duties  of  the 
soldier,  to  share  in  the  common  t"il  and  to  buf- 
fet with  tin-  element-.  The  irregular  mode  <>t' 
living,  to  which  the  majority  are  totally  uuac-i 
customed,  te  more  injurious  than  other  hard- 
ships which  they  daily  undergo,  and  to  the  san- 
itary influence  of  which  they  owe  unwittingly 
much  of  the  health  which  soldiers  enjoy.  Exer- 
oiw  in  the  open  air  counteracts  many  of  the 
would-be  injurious  effects  of  exposure.  The 
physical  improvement  is  surprising  which  the 
gloved  members  of  high  life  exhibit,  after  even 
a  few  weeks  campaign,  although  followed  under 
tin-    most    disadvantageous   circumstances   of   in- 

elelliellt     Weather. 

This  was  well  shown  among  the  troops  protect- 
ing the  batteries  in  the  neighborhood  of  Charles* 
ton  harbor,  prior  fco  the  taking  of  Korl  Sumter. 
When  the  cftll  i«>  arms  waa  tuo<le,  the  militia — 
composed   '"  «l  large  measure  of  clerks,  merchants 


MATERIAL    OF    ARMIES.  I 

and  professional  men,  most  of  whom  were  much 
more  familiar  with  the  duties  of  the  desk  Hum 
manual  labor — with  one  common  impulse  rushed 
lo  meet  the  enemy.  Many  of  them  of  delicate 
frames  and  frail  constitutions,  exposed  themselves 
upon  sandy  islands,  directly  upon  the  sea  beach, 
with  little  oi-  no  protection.  They  were  badly 
housed,  irregularly  led,  and  miserahl y  watered* 
Their  daily  duties  were,  with  pick  and  shovel,  to 
throw  up  redoubts,  establish  batteries  and  mount 
heavy  ordnance  during  the  day  ;  whilst  their 
nights,  when  not  spent  in  anxiously  watching  an 
expected  invasion,  or  performing  tedious  guard 
duty  during  a  spell  of  continuous  stormy  weather, 
was  forgotten  in  sweet  oblivion  upon  the  wet 
sand,  at  times  without  the  shelter  of  a  tent.  Not- 
withstanding, the  sanitary  condition  of  the  troops 
was  excellent;  and  many,  of  delicate  frame,  re- 
turned to  their  homes,  at  the  expiration  of  two 
months,  sturdy,  robust  men,  with  an  addition,  in 
some  cases,  of  twenty-live  pounds  weight  All. 
without  exception,  were  improved  by  the  change 
of  life,  under  the  exhilarating  influence  of  sea  air 
and  active  exercise. 

It    has   been    often    noticed    that    soldiers,    taken 

from     the     better     cl;i--c>     of    cit'l/.clis.    go     through 

campaigns   of  greal    exposure,  with    many   priva- 


*  u  ■  ;  MM  M.    OF     \RMTF.S. 

tioM;  much  better  than  tlie  lieavily-buill 
manry:  whicli  <an  be  accounted  for  in  1 1 » * •  per- 
sonal care  of  the  on--  :•  1 1<  1  the  known  car< 
of  ili«'  other.  For  the  same  reason,  officers  we 
comparatively  exempt  from  those  diseases  which 
ordinarily  till  the  hospitals  with  sick  from  the 
ranks.  The  immunity  frow  infantile  dieeasee  ie 
one  of  the  most  noted  reasons  why  city  troops 
sufier  lees  in  a  campaign  than  soldiers  from  the 
country.  All  armies  confirm  the  well-established 
tact  tliat  raw  recruits,  in  the  field,  always  suffer 
in. .it-  than  veterans.  In  the  Crimea,  thousands 
of  recruits  filled  the  hospitals,  en  route,  before 
arriving  at  the  seat  of  war.  These  troope  had 
bean  collected,  indiscriminately,  under  a  pressure. 
Many  of  them  wnv  young,  ill-conditioned,  undo* 
reloped  in  body,  unconfirmed  in  constitution,  and 
hence,  without  stamina  or  powers  of  enduraneei 
When  compelled  to  undergo  the  hardships  of  a 
siege,  where  the  strength  of  full-grown  men  soon 
failed,  they  were  rery  quickly  used  up.  I "mu-cus- 
tomed  to  cither  the  work,  food   or  exposure   to 

which  they  were  compelled  to  submit,  they  were 
readily  affected  by  diseases,  and  when  severely 
attacked,  they  usually  died  ;  or  if  they  survived, 
their  convalescence  was  painfully  prolonged,  and 
the   leasj    imprudence  produced   a  relapse.      Xa- 


MORTUARY    REPORTS    OF    THE    MEXICAN    WAR.  V 

poleon,  in  making  u  demand  for  troops,  asked 
for  men,  as  he  well  knew  that  boys  only  encum- 
bered  the  hospitals   and    roadsides. 

An  English  Crimean  Burgeon,  in  speaking  of 
the  character  o\'  the  troops  sent  to  the  East,  and 
of  the  hardships  to  which  they  submitted,  men- 
tioned, to  me  that  premature  old  age,  decrepi- 
tude, with  feeble,  bent  frames,  wrinkled  faces  and 
grizzly  locks,  were  seen  in  youths  of  two  or 
three  and  twenty — the  effect  of  two  winters  toil, 
want  and  misery. 

In  examining  the  statistics  of  the  Mexican  war, 
we  rind  the  well-established  rule,  that  volunteers 
sutler  more  than  regulars,  confirmed,  although  the 
material  of  which  the  volunteer  force  was  com- 
posed was  much  superior  to  the  average  of  armies 
from  conscriptions  or  forced  enlistments.  The 
troops  sent  out  from  the  States  were  picked  men, 
*  well  developed  in  bodily  frame  and  constitution, 
yet  a\c  find  a  fearful  disparity  when  we  compare 
the  mortuary  reports  of  the  three  different  arms 
of  the  seryiee. 

The  three  classes  of  troops  in  the  war  with 
Mexico  were:  the  old  or  standing  army,  composed 
of  men  accustomed  to  the  fatigues  and  routine  of 
a  soldier's  lite  ;  ten  regiments  of  enlisted  men, 
carefully    selected    by     recruiting    surgeons  :     and 


1"  M'-iUi  Ai:V    RKI><iRTS    OK    TIIK    Ml.  Mr  \\     WAR. 

U  volunteers,  taken  at  random  troru  all  walks 
of  lit«'.  The  total  1"--  in  the  aid  army,  by 
deaths,  discharges,  resignations  :in<l  desertions, 
exclusive  of  discharges  by  expiratiou  of  lervice, 
was  7.'. 188,  in  an  aggregate  force  of  Lo,736  ;  being 
•".".T'.1  per  cent,  for  the  whole  service  of  twenty-six 
mouths,  or  a  monthly  1<>>>  of  1. '•'•">  pe*  ceut  In 
ilic  ten  new  regiiueuts,  using  the  sawn'  basis,  tin- 
total  loss  was  3,£39  in  an  aggregate  strength  of 
11,186 ;  being  34.22  per  cent.  Ebr  the  whole  ser- 
vice ol  fifteen  months,  or  a  mouthly  loss  oJ 
|.rr  coat  In  the  regiments  ami  corps  of  volun- 
teer.-, the  total  loss  was  20,38o  in  an  aggregate 
force  of  73,260,  being  27.82  per  ceut.  for  the  aver- 
age period  of  service  of  ten  months,  or  a  monthly 
boss  of  ~2.~s  per  cent.     When   it    is  remembered 

that  the  old  annv  stood  the  hriiut  of  all  the 
early  engagements,  and  that  ninny  of  the  volun- 
teer regiments  were  never  in  battle,  the  dangers 
of  camp  life  to  volunteers  and  raw  recruits  become 
more  conspicuously  evident.  The  old  army  sus- 
tained a  Lost  of  o.,,:>>  per  cent,  from  killed  in 
battle  or  dying  from  wounds — a  loss  of  T'.'i!  men 
from  15,736..  The  ten  new  regime uts  met  with 
a  loss  of  148  from  11,186,  or  1,27  pet  cent. 
The   volunteer  corps,   numbering  73,260,    lost    in 


M    ii.-:il  St»tistici  U.  s.  Annv,  I  139  to  1854 


HF.ATHS    FROM    SICKNKsS    AND    WiMNhS.  11 

battle    and    from    wounds   only    Gbk    Of    0.88    per 

cent.,  whilst  the  actual  sick  list,  carefully  com- 
piled, and  le&ving  out  all  losses  to  tlie  armv 
cx.'e|»t  from  sickness,  amount  to  1~>,i>17,  or  20.8-3 
per  cent. 

These  statistics,  collected  with  -Teat  care  hy  the 
late  surgoo.i-general  of  the  Inked  Stales.  portray, 
in  vivid  colors,  the  effect  of  the  exposures  and 
hardships  of  an  active  campaign  upon  those  who, 
for  the  first  time,  adopt  the  life  of  a  soldier.  As 
not  only  the  valuahle  lives  of  citizen  soldiery, 
forming  morally,  socially,  pecuniarily,  our  very 
hest  people,  should  he  to  the  utmost  protected, 
but  also,  from  the  enormous  expense  and  troiihle 
incurred  hy  a  nation  in  training  and  in  transport- 
ing an  army  for  distant  service,  it  is  imperative 
that  the  medical  staff  labor  to  disseminate  among 
the  troops  those  rules  of  hygiene  which,  when 
considered  in  its  widest  sense,  are  so  profitable 
in   sustaining  an   ell'cctive  military   strength. 

We  have  jufit  seen  that  in  our  own  wars,  as  in 
all  that  have  ever  occurred.  ;in  army  is  rwrely  deci- 
mated hy  the  tire  of  an  enemy.  Tln»e  killed  in 
battle  are  hut  a  handful  when  compared  to  the  vic- 
tims of  disease.  In  Mexico,  our  army  of  HUljSiJ 
men,  in  an  average  campaign  of  seventeen  months, 
(.V|„.-c,l    |0   the   continued    tin-  of  an   enemy   who 


I  _'  lltiiM    SK'KNKSS    AXIl    WOl  ND8. 

y  inch  of  around  from  the 
i«»  their  capital,  making  ■  linn  stand  ;ii  every 
point,  Prom  which  they  had  to  be  driven 
under  a  murderous  fire,  lost.  l"it  l,54il  men  in  bat- 
rom  wounds,  all  told;  whilst  10,086  died 
in  M i\i<> »  from  disease,  besides  the  hundreds,  or  I 
would  be  well  within  bounds  when  1  -ay  thou- 
sands, who  returned  home  t<>  die  among  their 
friends  from  the  effects  of  diseases  contracted  in 
camp.  For  some  time  after  the  war,  volunteers 
formed  a  noted  proportion  of  the  inmates  of  civil 
hospitals,  and  the  chronic  diseases  under  which 
they  were  laboring  were  with  great  difficulty  coo* 
trolled. 

In  the  Crimean  Bervice,  the  statistics  collected 
by  Lord  Panmure,  minister  of  war.  show  the  Kng- 
li-h  loss  to  have  been  22,457,  of  which  number 
■  were  killed  in  battle,  or  died  from  the  eftecta 
of  wounds  received.  Whilst  the  French  loss,  as 
reported  to  his  (Government  by  \l.  Scribe,  inspec- 
eueral  of  the  French  medical  service  in  the 
('rim. -a.  exhibits  the  frightful  loss  by  death  of 
68,000 ;  whilst  the  admission  into  hospital  num- 
bered 1 1  I. <■'•-. 

Could  the  statistics  of  our  armies  from  the  1st 
of  July,  1861,  to   Lsl  January,  isii-j,  be  eotteoted, 

it  would    be    found   even    more   striking  than  those 


RECRUITING    SERVICE.  13 

already  mentioned.  Our  list  of  killed  and  -wounded 
has  been  very  small,  our  mortuary  and  sick  list 
enormous.  One  to  thirty  would  not  be  an  exag- 
erated  proportion  of  sick  to  wounded  in  the 
army  of  llio  Potomac  alone,  which,  of  all  others, 
has  been  most  exposed  to  the  fire  of  the  enemy. 

The  above  statistics  arc  sufficient  to  show  that 
the  efficiency  of  an  army  does  not  consist  in  its 
great  numbers,  but  in  the  sanitary  condition  of 
the  troops. 

The  duties  of  the  medical  staff*  arc  paramount, 
as  tin-  nation  should  look  to  them  as  much  as  to 
the  military  leaders,  for  the  successful  termination 
of  a  campaign.  Let  us  now  see  how  this  health, 
which  is  so  valuable  to  an  army,  can  be  preserved* 

Recruiting  Service. — The  first  protection  which 
an  army  has  is  in  the  recruiting  service,  which  is  a 
thorough  sifting  of  applicants  for  admission.  The 
duty  of  deciding  on  the  efficiency  of  a  recruit  de- 
pends upon  an  examination  made  by  a  recruiting 
officer  and  a  military  surgeon.  The  service  de- 
mands that  this  examination    be  thorough,  both  in 

regard    to  moral   and  physical   disabilities.      The 

regulations,   therefore,   enjoin,  that,    "in    passing 

ruit.  the  medical  officer  is  in  examine  him 

stripped,  to    see    that    he  has  the   free  use  of  all  hit! 


11  RKi  IUTITINO    KKR\  II   i 

limbs;  thai  his  chest  is  amjilo:  thai  his  hearing, 
>n  ;iiul  speech  is  perfect;  that  he  has  no  tu- 
mors, ulcerated  or  extensively  cicatrized  legs:  no 
rapture  or  chronic  cutaneous  attection ;  tlmt  he 
}i;i>  ii..t  received  any  contusion  or  wound  of  the 
head  thai  may  impair  his  faculties  ;  that  he  fa  nm 
a  drunkard,  is  not  subject  to  convulsions,  and  lias 
in.  infectious  or  other  disorder  that  may  unlit  him 
for  military  service.  The  surgeon  ts  alio  r«< juir.*! 
to  certify  <»ii  honor,  that  the  recruit  passed  by  him 
••  i-  free  from  all  bodily  defects  and  mental  infirm- 
ity, which  would  in  any  way  disqualify  him  from 
performing  the  duties  of  a  soldier;  and  Bhonld  it 
appear  that  the  recruit  was,  at  the  time  paaooMj 
physically  unfit  t<>  perforin  all  the  duties  i<»r 
which  he  was  mastered  into  the  service,;  the 
surgeon  who  recommeuded  his  acceptance  be- 
oomes  pecuniarily  liable  for  the  pay  of  the  sol- 
dim-  during  the  time  which  he  has  been  attached 
to  the  army.  A-  tie  recruit  must  be  between 
the  age  of  eighteen  and  thirty-five  years,  at  lea-t 
live  feet  lour  inches  in  height"  and  able-bodied, 
we  ean   understand   why  an   army  selected   by  l 

rigid  observance  of  the  above   regulations,   cm- 



required  in  tbo  French  army,  is  five  t' '•)  one 
inch;    in    t!>.    Ii.it.  - 1    Slat.-.-    arm;.  Ore  feel    four  and  B  half  imlic-  ;    in 
•li.-li   -■  r\  i    ■  In  i-  ami  a  half  Inchei  . 


RECRUITING    SKRVICE.  15 

posed  of  healthy,  robust  men,  in  the  vigor  of 
manhood,  when  brought  under  thorough  disci- 
pline, is  in  the  best  condition  to  preserve  a  high 
standard  of  health. 

To  show  with  what  stringency  the  laws  on  this 
subject  are  usually  observed,  we  gfive  the  recruit- 
ing list  of  the  United  States  Army  for  1852. 
The  total  number  examined  were  16.0(54,  of  these 
13,338  were  rejected  ;  2,276  were  alone  received 
into  the  service.  Among  the  causes  of  rejection 
arc  found  the  following:  Not  robust,  too  Blender, 
unsound,  broken-down  constitutions,  general  Un- 
fitness, imbecility,  unsound  mind,  epilepsy,  intem- 
perance and  bad  habits,  hernia  and  lax  abdominal 
rings,  varicose  veins  and  variocele.  hemorrhoids, 
syphilis,  gonorrhoea,  loss  of  teeth,  unequal  length 
of  limbs,  general  and  local  malformation,  con- 
tracted chest,  spinal  curvature,  old  injuries,  frac- 
fures,  etc. ;  cicatrices,  tumors ;  diseases  of  bones. 
joints,  skin,  heart,  testis  and  tunica  vaginalis; 
also  of  arms.  eyes.  ettTS,  glands,  chest,  throat  and 
abdomen  :  defective  hearing,  speech  and  vision  ; 
ulcers,  goitre,  ascetes  and  anasarca,  obesity,  etc 

When  wo  take  into  consideration  the   little  dis- 
parity of  age  with  the  absence  of  so   many  pre* 
disposing  causes  of  disease,   we  can   readily 
why  the   soldier,  by  profession,  has  so  great  an 


1'  M.oTIIINU    AN'1»    FOOD    FOH    TRoops. 

advantage  over  the  volunteer  force,  into  which 
any  one  ca]iahk>  of  performing  duty  is  received, 
however  untitteo!  he  may  be  phvsicallv  for  the 
toil  ami  privations  of  camp   life. 

To  "i -.tain   Tin:    i  FM0ST   <  \r\<rn    N   i.umi;    rim.M 
.Mi:\.    UK     Mi  -i     H     NtOPBB&l     CL9CHBB    UB    wr.i.l. 

rr.m— These  arc  the  prerequisites,  without  which 
their  powers  of  resistance  to  exposure  and  e*- 
oeesive  exertion  are  not  developed.  A  soldier  is 
compelled  to  familiarize  himself  with  many  oc- 
curreuces  which  experience  in  actual  war  shows 
io  In-  common,  lie  is  often  called  upon  for  la- 
borious work,  to  expose  himself  to  wind  and 
rain,  heat  and  cold,  to  suffer  hunger  and  fatigue, 
to  travel  at  night  as  well  as  during  the  Bay,  to 
sleep  dressed  and  accoutred  in  cloak  or  blanket, 

tie  must    be   taughl    when  thus   exposed    to   secure 

his  person  from  disease,  and  to  ward  off  inju- 
rious consequences.  In  short,  he  ought  to  be 
put  in  possession  of  the  best  remedies  for  every 
contingency  which  may  possibly  happen  in  mili- 
tary service.  This  is  particularly  the  case  with 
an    armed    body   who   may    be    called    upon    at    any 

moment  to  exert  great  efforts  in  making  forced 
marches,  and,  under  many  privations,  to  meet  b 

hold    ami     determined    enemy,    and    to    repulse    a 


CLOTTTIVG    OF    TROOPS.  17 

superior  force.  The  strength  of  an  army  U  culcu- 
fated  rather  by  the  physique  of  its  men  than  by  nit/Tu- 
bers, as  experienci  skoioS  that  men  who  ham  f>een 
well  taken  care  of  are  capable  of  opposing  success- 
ful doubk   the  force  badly  provided. 

To     PRESERVE     HEALTH     ANT)     EFFICIENCY,      TROOPS 

MUST  re  wet. i,  CLOTHED. — This  is  one  of  the 
weighty  questions  in  the  economy  of  an  army, 
and  lias  been  the  subject  of  much  study  and 
experiment  by  military  leaders. 

*The  object  ^\'  clothing  is  to  protect  the  skin 
from  diurnal  variations  or  annual  perturbation? 
of  the  atmosphere,  whilst  it  absorbs  excretions, 
and  thus  becomes  the  means  which  allows  man 
to  enlarge  his  native  sphere,  and  successfully 
resist  extremes  of  temperature  in  the  torrid  or 
frigid   zones,     The  caloric  properties  of  clothing 

■MlflA  be  considered  under  the  triple  relation  of 
absorption,     reflection,     and     conduction.        Every 

body,  whatever  be  its  temperature^  is  continu- 
ally throwing  oft'  heat  from  every  portion  of  its 
surface,  the  amount  of  radiation  depending  upon 
its  temperature   and  extent  of  surface.     The  hu 

y  mi    Bygiei  o,   1858.  station,  Discipline 

ami  Economy  <■)'  Armies. 


1  -  CLOTHING   Of   TffJ 

man  body,  having  a  Buperior  temperature  to  that 
of  the  surrounding  atmosphere,  reflects  1 1 « - r 1 1  bo 
Buch  :i  degree  as  would  be  incompatible  with 
Life,  were  it  nol  controled)  t<>  :i  great  extent,  bj 
the  nonqpnduction  of  living  tissue  and  the  pn 
tective  influence  of  clothing.  The  first  retards 
the  transmission  of  heal  from  the  centre  of  the 
body,  whilst  the  second  acts  as  a  Boreen. 

[f  two  bodies  unequaltv  heated  be  placed  in 
proximity  to  each  other,  there  exists  a  tendency  t<> 
produce  an  equilibrium  of  temperature.  A  third 
body  interposed  would  intercept  entirely  the  heal 
until  it  be  also  heated,  >«>  that  it  may  emii  from 
the  Bide  corresponding  to  the  <-"ld  body  thai  which 
it  absorbs  from  the  warm  body.  Clothing  placed 
between  man  and  the  atmosphere,  exercises  this 
protective  influence  in  proportion  t<>  its  power  of 
reflection  and  conduction;  and  as  clothing  is  a 
bad  conductor  of  heat,  the  outer  surface  of  the 
dress  >«•!< I< >i n  acquires  the  temperature  of  the 
person  which  it  covers.  The  incarceration  of  a 
layer  of  air  between  the  person  and  the  cloth- 
ing, and  also  that  which  enters  into  the  meshes 
of  the  cloth,  Btill  further  retards  the  transmis- 
sion of  caloric — heat  passing  to  and  through  the 
clothing  very  Blowly,  and  the  layer  of  incarcerated 
air  being  a   very   poor  conductor.     On  a   quiet, 


9 


CLOTHING    OF    TROOPS.  19 

cold  day,  when  we  arc  surrounded  by  a  little  at- 
mosphere of  our  own  warming,  we  feel  much 
more  comfortable  than  when  this  nonconducting 
layer  is  constantly  displaced,  as  on  a  windy  day, 
when,  although  the  thermometer  indicates  a  much 
higher  temperature,  the  cold  is  severely  felt. 

It  is  the  action  of  these  causes  which  explains 
why  the  exterior  of  the  clothing  of  a  soldier, 
bivouacked  without  shelter  under  the  clear  sky, 
is  colder  than  the  surrounding  air.  As  had  con- 
ductors, the  heat  which  escapes  from  the  skin 
traverses  slowly  the  thickness  of  clothing;  hut, 
as  soon  as  it  reaches  the  external  surface,  it  is 
radiated  or  emitted  rapidly.  The  protection  of  a 
tent,  or  even  a  cloak,  counteracts  this  radiation. 
The  inverse  protection  which  the  blanket  gives 
the  Spaniard  or  Arab  in  hot  weather,  is  similar- 
•  -oinited  for.  The  radiating  properties  oi 
wool  exceeds  its  conducting  or  absorbing  powers, 
and  throws  off  the  greal  heat  of  the  Bun  before 
it  can  penetrate  the  thickness  of  clothing  and 
reach  the  wearer's   -kin. 

Besides  the  property  jusl  enumerated,  the  by- 
grometric  powers  of  different  fabrics,  condensing 
moisture  from  the  air  and  absorbing  perspira- 
tion, are  of  much  importance  in  the  sanitary 
economy  of  clothing.     In  either  case,  their  power 


10  CLOTHlNti    Of    TK> 

of  contacting  heat  is  increased;  and,  therefore, 
the  more  moisture  they  contain  in  their  meshes 
•  1 « 1  < - 1-  they  are  as  appafel.  The  fluid  which 
Loth  imbibes  takes  the  place  of  air,  and  be- 
coinos  a  eausc  of  refrigeration  by  evaporation, 
robbing  the  neighboring  skin  of  its  heal  t<>  form 
aqueous  vapor.  Linen,  for  instance,  imbib< 
once  moisture  from  any  source,  and  chills  the 
body  by  the  evaporation  of  this  moisture;  fchis 
material  for  articles  <>f  clothing  exposes  the  bodj 

asations  of  *•« »1<  1  and  dampness,  and  n< . 
rily  to  the  diseases  which  arc  brought  >>n  by 
such  exposure.  Cotton  fabrics,  although  not  so 
attractive  to  moisture,  permil  absorption  and 
evaporation  to  a  considerable  extent;  whilst 
woollen  goods  condense  moisture  as  badly  as 
they  conduct  heat.  from  them  evaporation  goes  on 
so  very  gradually  as  scarcely  to  chill  the  external 
surface  of  the  clothing. 

The  hygrometric  properties  of  clothing  are  in- 
timately connected  with  their  action  upon  the 
skin,  when  considered  as  an  organ  of  absorption 
and  excretion.  Cutaneous  perspiration  varies  in 
quantity,  according  to  the  power-  of  conduction, 
radiation,  and  heat-absorbing  properties  of  cloth- 
ing, which  cannot  modify  the  exhalation,  ab- 
sorption   ;md    sensibility   of    the    skin,    without 


CLOTHINO    OF    TROOPS.  21 

reacting  npmi  its  functions.  The  energy  of  cu- 
taneous elimination  regulates  in  a  measure  the 
march  of  other  excretions.  Anything  which  im- 
presses tin-  nerves  oi"  the  skin  excites  equally 
fche  origin  of  these  nerves,  and  causes  exaltation 
or  depression  of  the  system.  Clothing  deter- 
mines the  antagonism  which  exists  between  ani- 
mal heat  and  external  temperature*  The  source 
of  animal  heat  increases  or  diminishes  its  activ- 
ity according  to  changes  in  the  atmosphere;  but 
the  unequal  production  <>i*  beat  causes  corres- 
ponding oscillations,  in  the  movements  of  res- 
piration and  circulation,  in  the  action  of  the 
muscles,  and  the  hrain.  Clothing  affects,  then, 
all  the  functions  of  the  economy,  and  may  clearly 
represent  the  question  of  health. 

A.8  the  object  of  clothing  is  usefulness  and 
convenience,  the  best  uniform  is  that  which  will 
protect  the  body  from  the  inclemencies  of  the 
weather*  and  whicb  least  impedes  the  move- 
ments wind]  are  connected  with  military  duties. 
Experience  in  the  field  teaches  what  can  be  dis- 
pensed with  or  what  can  be  added  with  advan- 
The  clothing  -elected  depends  much  upon 
the  habits  of  a  people  and  the  country  in  which 
1 1 1< ■  war  is  carried  on.  We  ,':"1  readily  nnder- 
1    how  absurd    ii    would    he   in   the    English 


m\<;    01    TltOOPS. 

Government  sending  their  home  troops  in  their 
thick  red  coats,  leathered  neoks  and  ahakoed 
heads  to  <\><  field  duty  on  the  scorching  plains 
of  India.  There  are  certain  portions  of  the 
clothing  which  experience  shows  conducive  he 
health,  in  all  countries  and  under  every  cireum- 
stai 

'/'/,,    clothing  for   troops  should  bi   mad*   of 
whether   the    material    hi    heavy   ur   liyht,    to   suit   the 
climate. 

The  soldier's  coot  should  be  a  frock  fitting 
\.  easy  over  the  shoulders,  -with  full  play 
for  tli*'  arms,  without  binding  in  any  way.  and 
\\i<U'  in  the  body,  so  as  n<>t  to  impede  the  ex- 
pansion of  the  chest  when  closely  buttoned.  The 
tail  of  a  coat  gives  much  protection  to  the  body 
an<l  abdomen;  whilst  a  jacket — which  is  a  very 
poor  costume  for  Boldien — -exposes  the  entire 
body  to  drafts  and  dampness,  fruitful  causes  of 
bowel  complaints.  The  trousers  should  be  of 
good,  beavy  woollen  material,  made  also  free, 
for  the  easj  plaj  of  the  limbs.  When  the  bot- 
toms are  faced  with* leather  or  enameled  cloth, 
it  is  found  a  great  protection  in  bad  weather, 
and  also  from  tli<'  dews,  keeping  the  legs  dry 
and  warm.  Flmuul  shirts,  coming  well  down 
upon  the  thighs,  and  drawers  ^l  the  same  mate- 


CLOTHING    OF    TROOPS.  23 

rial,  are  of  great  hygienic  utility,  and  should 
form  a  portion  of  the  dress  of  every  soldier, 
whether  he  has  been  accustomed  to  wear  flannel 
or  not.  In  winter  they  retain  the  animal  heat 
and  support  the  healthy  function  of  the  skin. 
whilst  in  summer  they  absorb  more  readily  the 
excess  of  perspiration,  which  occurs  under  se- 
vere  exercise.  Whilst  agreeable  to  the  wearer 
they  prevent  sudden  arrests  of  perspiration,  and 
are  thus  a  protection  against  diarrhoea  and  dys- 
entery, which  are  so  fatal  to  armies.  These 
should  be  furnished  in  sufficient  numbers  to  en- 
able the  soldier  to  change  his  shirt  when  Ik-  has 
been  exposed  to  rain,  as  he  may  thus  prevenl 
pneumonia  and  bronchial  affections,  so  common 
It   <  : 1 1 1 1 ] >    life. 

In    the    French    service,    where    flannel    under- 
clothing   is    not    in    such    conMant    use    as    in    the 

English  and  American  service,  every  soldier  car- 
ries a  band  of  llannel,  with  which  he  envelopes 
bis  abdomen,  as  a  safeguard  from  abdominal  af- 
fections. Baudens,  one  of  the  surgeons-in-chief 
of  the  Crimean   service,   speaks  of  this  band   ae 

(Essentia  1    to    the    health   of  the   troops,  and.  at    the 

samg  time,  refers  to  the  much  better  and  more 
convenient  protection  which  the  English  flannel 
shirt    gives  to   toe    men.     The   liability  of  losing 


•_'  I  OLOTHIWO    "F   TR-- 

the  flannel  gircHe,  and  it-  very  partial  protection, 
i-  :i  serious  objection  to  it-  use.  For  similar 
Bhould  always  be  given  to 
soldiers.  They  are  much  more  durable  than  ••■•t- 
t"n.  and  much  more  healthy,  preserving  an  equal 
temperature  ami  retaining  warmth  to  the  feel 
which,  being  at  the  greatest  distance  from  tlie 
centre  of  the  circulation,  are  leas!  capable  of 
ting  cold.  and.  therefore,  require  most  pro- 
tection against  injury.  They  also  afford  ■  i"t- 
ter  protection    against    the   chance   of    blistering 

than    aoeks    of   Other   material. 

Tin'  feet  are  pari  of  the  person  of  h  soldi* 
essential  for  the  performance  of  military  duty. 
that  their  condition  should  be  particularly  attend- 
ed to  by  the  officers.  Tfo  shoes,  boots,  or  half- 
boots  Bhould  be  well  made,  of  good,  {durable 
material,  and  well  fitted  to  the  loot,  so  as  to  be 

easy   to   the   wearer.      The   soles   should    he   hroad. 

thick  and  firm,  high  quartered  bo  as  to  exclude 
mud  or  sand,  and  closely  fitting  around  the  instep, 

90  thai  teiiaeioii-  (day  eaniiot  easily  drag  it  from 
the    foot.        A    good    shoe     or     hoot    add.      Often     tS 

much  to  the  efficiency  of  the  Boldier  as  a  good 
weapon.  Marching  is  as  necessary  a  quaUlv  as 
lighting,  ami  is  made  one  of  the  requisites  in 
! miiig  i   member  of  the    [mperial    Board  of 


CLOTHING    OF    TROOPS.  lio 

the  present  French  emperor.  "When  the  shoe 
docs  urn  tit  the  wearer,  "who  is  compelled  to  use 
them,  sore  feet,  a  very  tronhlesome  complaint 
in  the  army,  is  brought  on.  On  the  march  men 
arc  found  lagging  behind  from  lameness,  and, 
as  these  are  exposed  to  he  cut  off  by  maraud- 
ing parties  of  the  enemy,  it  heeomes  the  duty  of 
those  in  authority  to  prevent  this,  hy  never  de- 
livering to  a  soldier  a  pair  oi'  shoes  which  have 
not  been  tried  on  with  care.  The  leather  should 
lie  Well  smeared  with  grease,  oil,  wax,  tallow  or 
other  composition  to  make  them  water-proof,  soft 
and  more  durahle.  This  should  be  done  daily 
in  wot  weather.  One  pound  of  tallow  and  half 
pound  oi'  rosin  melted  together,  and  applied  hot 
with  a  painter's  brush,  and  renewed  until  neither 
sole  nor  upper  leather  Will  take  up  any  more,  is 
found  an  admirable  leather  preservative.  The 
grease  alone  would,  in  time,  rot  the  feather,  hut 
the  addition  of  rosin  gives  the  compound  anti- 
septic  properties. 

In  the  Crimean   service  the   Russian   half-hoot 
was  found  so   superior  an  article  over  the   hoots 

or  sho,-  of  the  Allies,  that  they  were  sought  for 
with  avidity  upon  the  dead,  as  soon  as  ihey 
Were  shot  down,  and  were  more  prised  than  any 
other  article    of   wearing    apparel,  so   conducive 


J<»  PLOT  til  Mi    »>K    TROOl'S. 

they  to  tin-  comfort  of  the  wearer.  Tliey 
protected  the  feel  perfectly  from  the  mud  in 
which  ilif  troops  lived  for  months. 

The  /•'/-/"■/'  gaiter  used  in  tin-  Crimea,  ww 
made  <>r  heavy  white  *-l < »t  1 1 .  covering  two-thirds 
of  the  foot  :iinl  extending  some  distance  up  the 
leg.  usually  over  the  knee.  It  facilitates  walk- 
ing, and  prevents  enlargement  of  the  veins, 
whilst  it  protects  the  limb  from  cold  and  wet 
Experience  in  the  field  and  upon  the  anarch  lias 
proved  them  bo  serviceable,  thai  the  entire 
French  army  i>  provided  with  them.  They,  a- 
a  substitute  for  the  boot,  might  be  added  with 
advantage  to  the  equipment  of  the  soldier.  When 
made  of  leather,  they  beeome  bard  after  getting 
wfi.  and.  Wy  pressure)  excoriate  the  ankle.-,  l'.e- 
udee  which,  the  leather  is  cold  in  winter  and 
very  hoi  in  summer.  The  only  advantage  in  the 
leather  gaiter,  is  durability;    the  cloth  wears  out 

much  sooner,  and  also  becomes  saturated  with 
moisture    in    rery   wet    weather.        In     addition,     to 

the  gaiter,  many  of  the  French  troops  wear 
greaves,  made  of  heavy  patent  leather,  which 
cover  the  leg  to  the  knee,  shutting  in  the  botr 
toni  of  the  pants.  This  gives  them  groat  facil- 
ities in  walking,  as  it  protects  the  leg  of  the 
pantaloon    from    becoming    foul   with   mud,   which 


CLOTHING    OF    TROOPS.  27 

is  an  endless  annoyance  to  troops  marching  in 
bad  weather. 

Every  soldier  should  have  an  overcoat  of  stout 
cloth,  reaching  below  his  knees*,  with  a  cape 
covering  the  shoulders.  This,  like  all  other  ar- 
ticles of  clothing,  should  be  made  easy,  to  per- 
mit of  any  movements  without  binding.  The 
French  have  added  a  hood,  to  protect  the  head 
and  neck  in  bad  weather  from  cold,  wind  and 
rain,  which  diminishes  the  frequency  oi^  catarrhal 
affections.  When  on  guard  duty  in  bad  weather 
they  are  of  great  utility,  and  also  to  protect  the 
head  and  neck  from  the  damp  ground  when 
sleeping.  Crimean  soldiers  found  this  addition 
;i  great  improvement. 

In  selecting  a  color  for  a  uniform,  it  should  be 
remembered  that  light  colors  aljeorb  less  than 
dark;  and,  also,  that  odoriferous  exhalations  ad- 
here with  much  greater  pertinacity  to  dark  than 
to  light  clothing,  which  is  an  item  of  no  small 
importance  when  the  deleterious  emanations  ac- 
companying large  bodies  of  men  are  considered. 
Besides  which,  experience  in  battle  shows  that 
certain  colors  make  much  better  marks  to  lire  at 
than  others;  and,  according  to  calculations,  a 
soldier  dressed  in  light  cloth  is  much  less  liable 
to  be  hit  than  in  dark.      The  following  percent- 


I  LOTH1NU    OF    in- 

age  i-  tin-  relative  liability:  red,  twelve;  rifle 
green,  seven;  brown,  six;  Austrian  bluish  gray, 
five.  Reel,  which  is  the  mosl  attractive  and  fa- 
tal    Color,    18     dlOre     than     twice     a>    1 1 1 1 1  •  - 1 1     SO    a- 

gray,  wnich  is  tin-  least. 

Tin  beat  military  liai  in  use  is  a  light,  bqA  felt, 
with  a  sufficiently  high  crown  to  allow  space  for 
air  over  the  brain.  The  rim  can  be  fastened  up' 
in  fair  weather;  and,  when  turned  down,  pro- 
tects, in  a  measure,  from  the  rain  or  from  the 
rays  of   the  sun.       In  a  warm   climate,  the  light 

Color  of  the  hat  adds  much  to  the  Comfort  of  the 
wearer.  The  small.  French,  jauntily-lit!  in-'  kepi 
IS     light,     hut     does     not     protect     the     lace;     and, 

when  made  of  dark   materials,  concentrates   the 

solar   rays   upon    the   head.      This  can   he  obviated 

by  adding  a  ETaveloek.  It  consists  of  a  cap- 
cover  with  a  long  cape  attached,  which,  hanging 
down  upon  tin'  shoulders,  protects  the  neck  from 
the  -mi  in  the  day  and  draughts  at  night.  It  is 
made  of  lighl  cloth,  of  a  Light  color,  for  reflect- 
ing leal.  Those  who  have  wmn  1 1  n  1 11  on  a 
march,  or  when  exposed  to  the  sun's  rays,  -peak 
in  extravagant  term-  of  the  comfort  ami  protec- 
tion whicii  ill.  \  give.  The  advantage  of  wear- 
ing a    light    and    high-crowned    hal   is   that,    under 

exposure  t<>  the  sun,  a.-  during  a  march,  a  -mall, 


CT.OTUINc;    or    TROOPS. 


20 


wet  handkerchief  placed  in  tin-  crown  will  not 
only  preveut  sun-stroke,  but  will  add  much  to 
the  comfort  of  the  soldier. 

According  to  the  army  regulations  of  the  Con- 
federate service,  a  soldier  is  allowed  the  (inform 
and  clothing  slated  in  the  following  table,  or  arti- 
cles  thereof  of  equal  value: 


CLOTHING. 


Cap.  complete 

"     rover  

!,.;,( 

Trousers 

Flannel  sliirt 

Flafrinel  drawers 

es,*  pairs 

Stockings 

],■  al  1m  r  stock 

Great  ooat 

Stable  frock  (For  mounted  men ) 

Fatigue  overall  (for  engineers  and  ordnance) 
Blankei 


FOR    THREE    TEARS. 

1st. 

2.1. 

a*. 

i 
i 
l 

2 
3 
2 
1 
4 

2 
1 

2 
3 

3 
3 

1 
4 

1 
1 
1 

1 
1 

1 
1 
1 

2 
3 
2 
4 
4 

1 

1 
1 

Total 

for 
three 
\  ears. 


In  the  field,  there  should  be  always  a  supply  of 
clothing  at  hand,  to  replace  the  loss  by  unavoid- 
able accident.  During  the  Crimean  service.  Dr. 
McLeod  informs  us  that  the  deficiency  of  cloth- 
ing, which  was  so  much  complained  of,  was  one 
of  the  nio8l  prolific  Bourcee  of  subsequent  disease 


'Mounted  men   maj   raoerve  am   ]>:iir  of*  boots,"  and  f«o  | 
"boob  ad  of  four  pair  of  book 


I  LOTHTXO    OF    TROOPS. 

among  the  finglish  troops.  The  truth  of  this 
statement  was  corroborated  by  experience  in  the 
Confederate  campaign  of  1861,  where  a  great 
amount  of  Bickness  could  be  traced  to  insuffi- 
cient clothing. 

('He  of  tin'  universally  admitted  maxima  for 
preserving  health  in  a  campaign,  irrespective  rff 
climate  or  Locality,  is.  that  soldiers  must  j>,-<<>t,-i 
themselves  m  summer  from  nigfd  air  by  warm  cloth- 
ing. 

A  heavy  blanket,  not  in  name  but  in  weight, 
ami  dp'  and  a  half  yards  of  india-rubber  cloth, 
complete  the  equipment  of  a  soldier.  The  india- 
rubber  cloth  is  a  waterproof  covering  for  him 
during  exposure,  and  will  always  make  for  him 
a  dry  bed,  upon  which  he  can  find  health  as  well 
as  comfort. 

We  make  the  following  extract,  on  the  extent  oi 
a  soldier's  equipment,  from  Jackson*s  Formation, 
Discipline  ami  Economy  <>f  Armies.  In  the  form 
ami  fashion  of  a  soldier's  equipment,  "the  aajnst- 
ment  of  the  kind  and  quantity  of  articles  termed 
necessaries  is  a  matter  of  importance,  and  as  such 
requires  to  he  well  considered.  It  is  demonstra- 
bly proved,  to  the  conviction  of  all  persons  who 
haw  served  with  armies,  that  superfluous  bag- 
gage, that   is.  baggage  beyond  the  narrowest  mca- 


CLOTHINf!    OF    TROOPS.  31 

sure  of  utility,  instead  <>f  bringing  comfort  to  the 
possessor,  js  a  cause  of  *>:ro:i  1   annoyance  ami  vex- 
ation.     A   complete  change  of  the   smaller   parts 
of  dress,   in    the    event   of   being   wet    with    rain, 
together  with  a  cloak  as  a  covering  for  the  night. 
is  all   that   a   soldier  requires  for  his  comfort  and 
the  preservation  of  his  health:  and.  as  such,  it  is 
all    that   he    ought    to    he    permitted    to    possess. 
Where  persons  have    not  more  than   one  change 
of   raiment,    the    strong    impression    of    necessity 
Obliges  them  to  prepare  for  the  return  of  want. 
Whore  there   is   a    superfluity,  the  necessity  does 
not  present    itself  so  Forcibly,  and  hence  the  dirty 
clothes   are    crammed    into   the   knapsack,   where 
they  accumulate  in  quantity  without  obliging  the 
individual    to    recollect   that    they  are    not   tit   for 
use  until  they  are  Washed:      It  thus  often  happens 
that  a  soldier  who  has  four  or  more  shirt:-  in   his 
possession,  has  not  one  til  for  use.  while  a  soldier 
Who  possesses   no  more  than   two,  has  generally 
one    in    his    knapsack    ready    for    the    contingent 
occasion." 

*  The  following  is  considered  to  D€  a  full  equip- 
ment for  a  soldier  on  service,  namely:  two  flannel 
shirts;    two  pair  of  woollen  socks:   two  pair  of 


•  Jackson's  Formation,  Dia  iplinc  and  Economy  "f  Armies. 


:;_•  i  i.m  ni  i  \«,  i.i    i  aoops 

el  drawers;   two  pair  of  shoes,  or  one   pair 
of  shoes  and  one  of  half  boota  :  one  pair  of  gait- 

& 'small  case  ol  needles,  thread  and  Imtt 
for  mending  ». - 1  < > 1 1 1 « ■  - :  one  small  shoe-brush,  with 
blacking;  comb  and.  hair-brnsh:  tooth-brush;  one 
piece  of  soap;  a  sponge  for  washing  the  body, 
ami  a  towel  for  drying  it:  two  i »* >«k*t  handker- 
chiefs; an  overcoat  of  heavy  material,  besides  his 
uniform.  He  should  also  lave  a  heavy  blanket  — 
better  if  lined  with  stout  osnaburgs  to  increase 
durability  and  warmth — and  two  yards  of 
india-rubber  cloth  to  protect  him  from  the  wepr 
ther.  lie  should  also  carry  a  knife,  fork  ami 
spoon,  a  canteen  for  water,  and  a  haversack  for 
carrying  dressed  provisions,  If  those  articl 
clothing  not  in  use  be  put  up  in  a  neat  and 
compact  manner,  ami  enveloped  in  oiled  silk  so 
as  to  be  secure  from  wet,  and  deposited  in  the 
knapsack  for  easy  carriage,  the  soldier  will  not  be 
incommoded  by  the  bulk  or  encumbered  by  the 
weight;  ami  possessing  withiu  himself  everything 
actually  necessary  for  use,  will  be  independent  of 
tLc  accidents  so  common  to  the  baggage  wagons. 
In  the  above  list  we  have  purposely  omitted 
shaving  apparatu  >cry   Boldier  in   the   held 

should  allow  his  heard  to  grow.     It   protects  his 
throat,  ami  often  prevents  lung  diseases,  catarrhal 


PERSONAL    CLEANLINESS.  33 

affections,  etc.  A  heavy  moustache  is  known  to 
protect  the  wearer,  to  a  certain  extent,  from  mala- 
rial influences,  acting  as  a.  sieve  to  the  lungs.  It 
also  purities  from  dust  the  atmosphere  inhaled 
during  marches,  and  thereby  prevents  many 
troublesome  diseases.  Cleanliness  dictates  that 
tlu-  hair  he  cut  close  to  the  head,  and  although 
the  heard  he  allowed  to  grow,  it  should  also  he 
kepi   within   hounds. 

Cleanliness. — Nothing  contributes  more  to  pre- 
serve health  than  personal  cleanliness:  and  as  the 
t>ee  use  df  soap  is  a  pro] ihvlactic  as  well  as  a 
civili/cr.  it  should  he  regularly  distributed  to  the 
men.  Daily  ablutions  should  never  he  omitted: 
and,  if  possible,  the  chest  and  arms,  as  well  as  the 
face  and  neck,  should  he  well  sponged.  Bathe 
should  he  used  whenever  opportunity  permits. 
Keeping  the  skin  clean  prevents  fevers  and  bowel  com- 
plaints  in  warm  climates,  Baudens,  in  insisting 
upon  cleanliness,  says,  "that  the  contrast  in  the 
sickness  and  mortality  of  the  Euglish  and  French 
camp  in  the  Crimea,  can  he  in  a  measure  attrib- 
uted to  the  frequent  ablutions  of  the  English,  who 
washed  their  clothes  in  hot  water,  and  changed 
their  underclothes  twice  a  week.  It  is  easy  to 
understand  how  carelessness  in  this  respect  will 
impair  the  functions  of  the  skin,  and  induce  dis- 


31  PKRSONAL    <  I. i:\M.l\i  SS. 

ease.  At  review,  our  French  soldiers  show  new 
clothes.  and  on  the  whole  an  unquestionable  mil- 
itary equipment,  yet  these  beautiful  battalions 
leave  in  their  _«•  m  strong  smell  of  barracks 

not  to  1"-  mistaken/' 

"\<>t  only  the  bents,  bul  the  persons  of  soldiers 
as  well  us  their  clothing  should  be  daily  inspected. 
However  particular  men  may  be  in  civil  life,  afe 
soon  as  they  are  pul  into  the  field  not  only  are  all 
habits  of  cleanliness  neglected,  which  we  would 
have  supposed  had  been  incorporated  with  their 
very  nature,  but  men  actually  take  a  pleasure  in 
being  careless,  and  comment  upon  the  little  need 
of  corporeal  ablutions,  hays  pass  without  the 
use  of  water,  and  tilth  and  vermin  soon  reign 
triumphant.  One  of  the  strongest  reasons  why 
regulars  enjoy  better  health  than  volunteers,  te 
that  the  <>nc  arc  daily  inspected  by  their  officers, 
who  insist  upon  their  faces  being  washed,  head 
combed,  etc.;  whilst  the  volunteers,  with  whom 
the  regulations  of  a  Btrict  discipline  are  not  en- 
forced, are  allowed  t<>  abuse  Che  privilege  of  fol- 
lowing the  heiit  of  their  own  inclinations.  It  h 
deplorable  to  Bee  the  condition  of  our  best  society 
in  camp.  In  the  Confederate  hospitals  it  was  not 
rate  to  administer  the  first  hath  to  volunteers  who 
had  been  >i\  months  in  service,  without  ever  hav- 


FOOD    OF    THE    SOI.WF.R. 


35 


fog  used  water  beytJnfl  their  laces.  It  would  1)0  a 
saiutary  regulation  of  groat  value  if  general  ablu- 
tions could  be  made  a  portion  of  &e  daily  drill. 
A  heavy  penalty  of  extra  fatigue  duty  should  be 
imposed  upon  those  who  did  not  daily  moot  the 
requirements  of  hygiene"  and  cleanliness. 

It  should  t>e  tho  duty  of  the  nietftcal  officer  to 
fequesl  the  commanding  officer  to  insist  that  tin  — 
hvgicnie  regulations  be  rigidly  enforced.  Ho  is 
not  only  tho  best,  hut  also  will  become  tlio  iflOSt 
popular  officer,  who  attends  himself  to  these  de- 
tailed comforts  of  his  men. 

Food  of  tho  soldier  should  be  plain,  nutritious 
tare,  well  cooked,  which,  with  exercise  as  an  appe- 
tizer, he  will  tind  no  difficulty  in  enjoying,  how- 
over  monotonous  his  daily  ration  may  he.  For  a 
workingman  (and  where  do  men  lahor  more  than 
the  Boldiet  in  the  field?)  the  diet  should  he  of  a 
mixed  character,  and  rood  should  he  «,t  the  va- 
riety   easily   COofeed.      The    character  of  the    diet, 

however,  nrasl  depend,  to  a  certain  extent,  upon 
the  seasons  and  the  ahility  of  the  commissary  i«» 
nreei  the  demands  of  the  army.  The  fundamen- 
tal mlo  in  the  culinary  art  is.  boil  slowly  and 
raw!  quiekly.  Highly  seasoned  dishes  arc  neither 
possible   nor  desirable  forf  ihc  sofflier.     Toil,  fa- 


■  ■'•  roOD   Of  Tin:   SOLDI] 

tigue,  and  often  hunger,  will  make  any  whole- 
some food  savory.  "The  plain  repast  is  sufii- 
cienl  for  sustenance :  and  ;i  plain  repast  gives 
all  ilif  gratification  t<>  the  palate  of  a  hungry 
and  thirsty  man  that  a  soldier  ought  to  permit 
himself  to  receive,"* 

For  the  English  there  ua  n<>  beverage  Like  fcea; 
and  a  military  writer  remarks,  that  a  breakfast 
of  tea  with  bread,  enables  a  person  to  sustain 
the  fatigues  of  war  with  more  energy  and  endur- 
ance than  a  breakfast  of  beeksteak  and  porter. 
The  French  prefer  coffee,  t<>  which  they  give  the 
highest  prophylactic  virtue.  This  is  the  stimu- 
latiug  drink  of  the  troops,  and  its  free  use  makes 
the  men  much  more  healthy  and  cheerful.  It  is 
at  ail  times  an  excellent  substitute  for  aleoholic 
beverages,  which  disorganize  an  army  by  tempt- 
ing to  drunkenness.  Whiskey  should  only  he 
given  out  to  men  on  very  exposed  duty,  or  in 
very  had  weather,  and  it  is  a  question  whether 
a  cup  of  hot  coffee  is  not  preferable  even  under 
these  circumstances.  The  common  abuse  of  spir- 
its, and  thf  doubts  of  the  necessity  of  using 
liquors  in  thf  Bervice,  are  strong  reasons  for  dis- 
carding intoxicating  drinks  from  the  army.     The 


J> Ill V    of  Allllii  8. 


FOOD    OF    THE    SOLDIER.  37 

health  of  an  army  is  always  better,  accidents  al- 
wiys  fewer,  and  insubordination  at  a  minimum 
when  spirits  cannot  be  procured.  Military  com- 
manders generally  denounce  whiskey  as  the  bane 
of  the  service.  The  Confederate  loss  by  fetal 
accidents  from  the  discharge  of  pistols,  carelessly 
handled  by  drunken  men,  has  been  nearly  as 
great  as  from"  the  halls  of  the  Federalists. 

The  Turks  place  great  reliance  on  coffee  as  a 
preservative  against  dysentery;  and  McLeod  states 
as  a  result  of  his  Crimean  experience:  liI  have 
no  doubt  that,  if  the  precaution  had  been  taken 
to  supply  the  tfOOps  every  morning  with  hot  cof- 
fee, as  they  went  on  or  returned  from  duty, 
much  of  our  mortality  might  have  been  avoided." 

A>  roasted  and  ground  coffee  has  become  a 
fixed  article  of  trade,  it  would  be  much  better 
for  the  troops  if  it  could  be  served  out  in  this 
form,  mixed  with  a  due  proportion  of  sugar,  par- 
ticularly when  they  arc  upon  extra  duty,  as  it 
not  only  saxes  them  much  time,  but  insures  the 
proper  preparation   of  a  BUpporting  beverage. 

If  coffee  cannot  he  obtained,  the  best  substitute 
is  a  pint  of  hot  soup,  which  might  be  prepared 
from  fresh  beef  when  this  article  is  abundant: 
hut,  what  is  still  bettef  tor  army  purpose-,  from  a 
spiced  soup-cake,  which  i-  made  of  choice  portions 


:'.S  FOOD    OF    THE    SOLDI  Kit. 

of  beef,  farinaceous  ingredients  and  spices — the 
whole  cooked,  compressed  and  desiccated.  These 
cakes  occupy  but  a  small  Bpace,  can  be  easily 
carried;  will  keep  for  mouths,  and.  by  cutting 
them  up  in  the  proportion  of  a  pint  oi  boiling 
water  for  each  cake,  and  allowed  to  boil  (pr  ten 
or  fifteen  minutes,  0  pint  of  excellent,  well  ila- 
yored  soup  can  be  made.  It  requires  no  longer 
to  make  a  pint  of  good  soup,  with  one  of  Jones' 
soup  cakes,  than  would  be  require^]  to  make  a 
cup  of  coffee,  with  the  coffee  already  paxche^ 
and  ground. 

It  may  be  needless  to  say  that  good  water  is 
even  more  necessary  than  good  food,  and  should 
be  obtained  at  any  cos!  for  the  use  of  the  troops. 
There  is  no  one  item  bo  prolific  in  disease  as 
drinking  bad  water.  Should  troops  be  so  unfor- 
tunate as  to  be  in  a  place  where  stagnant  it 
ditch-water  bas  to  be  used,  it  can  be  purified  by 
boiling  with  a  lump  "1  charCoal  :  alter  which  it 
should  be  freely  agitated  in  the  air.  to  restore  to 
it  the  vivifying  properties  which  the  heai  had 
driven  oil'.  Should  tin-  water  be  turbid,  :i  piece 
of  alum  thrown  into  a  bucketful  will  quickly 
settle  the  de]io>'n  ;iml  restore  its  crystalline  char- 
acter. Ii  more  time  be  allowed,  the  better  plan 
would  be  to   filter  the   water  by  sinking  a  barrel 


FOOD    OF    THE    SOLDI  KR. 


with  holes  bared  in  the  side  ;  into  this  n  much 
smaller  barrel  with  the  bottom  knocked  out  is 
placed,  and  the  intervening  spaee  between  the 
barrels  filled  with  straw.  The  water  which  passes 
through  the  holes  leaves  all  impurities  upon  the 
straw,  and  springs  up  as  clear,  potable  water  in 
the  smaller  barrel. 

Fresh  meat  and  vegetables  should  he  served 
out  to  troops  whenever  they  can  he  had,  and 
the  best  mode  of  cooking  them  is  in  soup.  A 
French  military  proverb  says  that  "soup  makes 
the  soldier."  The  free  use  of  fresh  vegetables 
is  the  only  mode  of  preventing  the  appearance 
ni'  scurvy  among  the  troops.  "When  these  can- 
not lie  obtained,  the  free  use  of  dried  vegeta- 
bles, a-  rice,  potatoes,  cornmeal,  etc.,  will  tend 
to  sustain  health   and   vigor. 

One  of  the  worst  articles  which  can  he  issued 
t<>  troops  in  the  Geld,  without  conveniences  for 
cooking,  is   wheat    Hour.      Fresh    bread    all    will 

■ 

acknowledge  to  be  good  Cane,  and  is  always  hailed 
with  satisfaction;  hut  to  issue  raw  Hour  as  the 
vegetable  element  of  a  ration,  with  no  means 
of  cooking  it  into  an  edible  bread,  is  an  act 
of  cruelty  to  troops  who  have  no  means  of 
ebtaining  other  food  than  that  which  the  commis- 
sary  allows.      In    our    corn    country,   where    corn- 


OF    THE    SOLDIKR. 

meal  or  grist  ie  a  common  article  o"f  food,  a 
staple  liked  by  nil.  and  the  mode  of  cooking  it 
easy  and  familiar,  the  article  it-elf  abundant, 
cheap,  ami  forming  the  very  best  food  for  man, 
why  this  article  should  not  In-  generally  issued 
instead  of  unwholesome  Sour,  which  fan  only  be 
made  into  die  most  indigestible  of  dough  cakes, 
in!,,  which  the  teeth  Btiok  in  vain  attempts  ;it 
mastication,  cannot  be  satisfactorily  explained. 
Economy,  the  health  of  the  troops,  and  general 
satisfaction  in  the  army,  Would  he  the  result  oi' 
the  change  from  wheat  to  eornmeal.  If  orders 
were  issued  io  carry  portable  ovens  with  the 
troops,  so  that  good  bread  could  he  daily  pre- 
pared, which  can  very  easily  hi'  done:  or  if  ovens 
were  built  wherever  troops  locate,  then  would 
flour  he  a  useful  issue,  hut  under  no  other  con- 
dition. 

A  distinguished  military  surgeon  has  remarked 
that  100,000  francs  spent  in  fresh  vegetables, 
will  save  500,000  francs  from  the  expenses  <>f 
sick    soldier,-    entering    the  hospital,   besides  the 

nse    of  the    men    lor   active   service.      Of  the    diied 

vegetables,    rice   is   among   the   best    for   feeding 

troops.     It   is  easily   carried,  easily  cooked,  easily 

-ted.    and     is     one    of    the    mottl    wholesome    of 

the  farinaceous  articles — correcting,  as  it  often 
does,  the  tendency  to  intestinal  ilu 


F001>    OF    TIIK    SOLDIKK.  41 

Tu  the  Crimea,  where  the  temporary  absence 
of  fresh  vegetables  was  a  great  and  serious  pri- 
vation, lime-juice,  citric  acid  and  BOUr-crout  were 
extensively  used  to  prevent  and  to  stop  scurvy. 
Acid  frtfits  arc  anti-scorlnitic,  and  very  good  for 
soldiers.  The  English,  in  the  Crimea,  gave  out  a 
ration  o\'  lenion-jnice  three  times  a  week,  which, 
when  mixed  with  mm  and  sngar,  made  a  very 
nice,  healthy  drink.  This  corrective  protected, 
to  a  certain  extent,  the  English  soldiers  from  scur- 
vy, whilst  with  the  French  it  was  widely  epidemic 
and  very  fatal.  Vinegar,  when  freely  distributed, 
also  assists  in  preventing  this  scourge  among 
troops.  Vinegar,  molasses  and  water,  when  mixed 
in  proper  proportions,  make  a  very  refreshing  and 
palatable  drink,  not  unlike  lemonade,  and  pos- 
sessing similar  anti-scorhntic  properties  to  lemon- 
juice. 

Biscuits,  or  hard  bread,  is  a  common  article  of 
diet  in  camp  life,  because  it  is  easily  preserved 
and  transported.  When  eaten  as  dry  biscuit,  it 
acts  like  a  sponge  in  the  month,  exhausting  sali- 
vary secretion,  ami,  tiring  the  jaws,  it  produces 
surfeit.  When  possible,  and  rarely  is  it  incon- 
venient, soak  it  in  tea.  coffee  or  goup ;  il  then 
makes  a  very  nutritious  meal.  Even  water,  with 
a  little  salt,  makes  it  much  more  palatable  and 
I 


4_'  nun.  ub    tiik  soi.ini  k 

nourishing.       Fresh    bread    is    always    preferable 

when  it  c;ui  be  obtained. 

Bacou  ia,  par  excellence,  the  laborer*'  and  sol- 
dier-' meat  in  Aineriea,  and  goes  further,  l>v 
weight,  than  any  other.  Ii  never  produces  >nr- 
feit,  is  always  acceptable,  very  easily  cooked,  ami 
with  its  rich  juice  will  make  tire  dryest  farina- 
ceous diet  savory.  It  has  the  very  great  advan- 
tage, when  properly  cured,  <>f  keeping  for  a 
length  of  time,  under  any  condition,  which  makt 
it   far  preferable  to  any  other  meal  for  troeps. 

In  the  Confederate  service,  the  ration  consists 
"f  three-quarters  of  a  pound  of  pork  or  haeon, 
or  one  and  one-quarter  poinds  >»i  fresh  <>r  .-alt 
beef;  eighteen  ounces  of  bread  or  flour,  or  twelve 
ounces  of  biscuit,  or  one  and  one-quarter  pounds 
corn  meal;  and  at  the  rate,  to  one  hundred  ra- 
tions, of  eight  quarts  of  peas  <>r  beans,  or  in  lieu 
thereof,  ten  pounds4  of  rice,  six  pounds  of  coflee, 
twelve  pounds  <>f  sugar;  also,  four  quarts  <>f 
vinegar.  The  rati. in  is  completed  by  adding  one 
and     one-half    pounds    of    tallow,     one    and     oiie- 

quarter  pounds  of  adamantine,  or  one  pound  of 
sperm  candles,  four  pounds  of  soap,  and  tun 
quarts  <>f  sail  to  one  hundred  rations.  <>n  a 
campaign,  or  on  marches,  or  «>n  hoard  transports, 
the  ration  of  hard   bread  is  one  pound. 


EOOD    OF    THK    SOLDI  KK.  4o 

Extra  issues  ©f  soap,  caudles  and  vinegar,  are 
permitted  lo  the  hospital  when  the  surgeon  docs 
not  avail  himself  of  the  commutation  oY  the 
hospital  rations,  or  when  there  is  no  hospital 
fund. 

Desiccated  vegetables  may  be  issued  once  per 
week,  in  lieu  of  beans  or  ricej  and  should  a 
tendency  to  scurvy  appear  among  the  troops, 
the  commanding  officer  may.  by  advice  of  the 
medical  officer,  direct  their  more  frequent  issue. 
Two  "issues"  per  week  of  '•desiccated  vegeta- 
bles" may  be  made  in   lieu  of  beans  or   rice. 

Potatoes  and  onions,  when  used,  will  always 
he  in  lieu  of  rice  or  bean  a.  1'olatoes  at  the 
rale  of  one  pound  per  ration;  onions  at  the  rate 
of  three  pecks  per  hundred  ration-. 

When  fresh  beef  can  be  provided  bo  as  to 
co.-t  not  mere  than  six  and  a  quarter  cents  pei- 
pound,  net  weight,  or  not  more  than  an  equiva- 
lent proportion  of  salt  pork,  it  will  he  issued 
to  the  troops  five  times  per  week. 

\\  In-ii.  from  excessive  fatigue  or  exposure,  the 
commanding  officer  may  deem  it  necessary,  be 
may  direct  the  issue  of  whiskey  to  the  enlisted 
men  of  his  command,  no;  bo  exceed  a  e-in  p,.p 
man  for  each  day. 

Tea    may  be    issued    in    lieu  of  coffee,  at    the 


4  J  FOOD    OF    THK    SOLDIER. 

refe    "t'    "lie    and    a    half    pounds    per    hundred 
rations. 

When  the-  officers  of  the  medical  department 
Mm!  anti-scorbutics  necessary  for  tlie  health  of 
the  troops,  the  commanding  officer  may  order 
issues  of  rVesb  vegetables,  pickled  onions,  sour- 
crout  or  molasses,  with  an  extra  quantity  of  rice 
and  vinegar;  potatoes  ire  usually  issued  at  the 
rate  of  our  pound  per  ration,  and  onions  at  the 
rate  of  three  bushels  in  lieu  <>t'  one  of  beanB. 
Occasional  issues  (extra)  o1  molasses  are  mad< — 
two  quarts  to  one  hundred  rations;  and  of  dried 
apples,  of  from  one  to  one  and  a  half  bushels  to 
one   hundred   rations. 

When  anti-scorbutics  are  issued,  the  medical 
officer  will  certify  the  necessity  and  the  circum- 
stances which  cause  it.  upon  the  abstract  of 
extra   issues. 

Daily  issues  of  rations  should  bt  made  to  the 
troops;  for  when,  from  the  laziness  of  cow 
missaries,  two  or  three  days  rations  are  given 
out  at  a  time,  through  the  proverbial  careless- 
ness or  improvidence  of  soldiers,  the  provisions 
are  either  wasted  or  all  arc  eaten  in  one  day, 
and  two  days  starvation,  it'  not  sickness  from 
jji  >rmandizin£r,  t'<  illows. 

A.s   Boldiera    are   expected   to   cook    their  own 


FOOD    OF    THK    SOLDIER.  40 

provisions,  and  as  all  are  familiar  with  the  fact 
that  as  much  depends  upon  the  mode  of  cook- 
ing as  upon  the  articled  cooked,  it  would  be 
better  to  have  one  of  the  mess  appointed  special 
oook  than  to  allow  the  Boldiers  to  cook  in  turn. 
A  division  of  labor  is  clearly  the  preferable  plan. 
It  would  be  economical  and  beneficial  if  Gov- 
ernment would  allow  too  professed  cooks  for 
eneli  company,  as  the  health  of  the  army  would 
be  improved  materially  by  having  good  fare. 
Firewood,  of  course,  must  be  liberally  provided, 
as  it  is  one-half  of  a  soldier's  existence. 

The  entire  health  of  troops  depends  upon  the 
quality,  quantity,  variety,  and  the  regularity  with 
which  the  provisions  are  supplied.  The  effect- 
ive condition  and  strength  of  the  army,  with  a 
diminution  of  the  sick,  and  consequently  a  dimi- 
nution in  the  hospital  expenses,  will  depend  in 
a  great  measure  upon  the  commissary  depart- 
ment. In  1847,  the  high  price  of  provisions 
doubled  the  number  of  siek  in  the  Freneh  army, 
sending  one-fifth    of    the    effective    regiments    into 

the  hospitals.  The  better  paid,  Beleel  corps,  who 
could  increase  their  supply  <»f  nourishment,  •  - 
caped  those  diseases  which  ravaged  the  common 
soldier.  Experience  show-  that,  in  a  besieged 
city,  when  scarcity  prevails,  pestilence  follows  in 
the  wake  of  famine. 


4<i  I  <-,,;.    OS    I  UK    BOLPJ  I 

-  ;iik1  toldiere  usually  club  together  into 

as  thia  living  together  i>  not   only  much 

mora   agreeable,   but    also   profitable   for  ;ill  <-.ui- 

cerued.      The     following    appears   to    have    been 

compiled  bv  an  experieueed  soldier: 

"Officers'  messes  should  consist  of  the  com- 
pauy  omceri — four  persona.  The  colonel,  lieu* 
tenant-colonel,  major,  adjutant  and  sergeaut- 
niajor,  with  the  commissary,  quartermaster,  Mir- 
geon,  assistant  Burgeon  :ui<1  chaplain,  oould  eaajw 
lv  arrange  two  mess<  i. 

"  Meases  of  privates  Biid  non-commissioned 
officers  should  number  six  persons,  for  obvious 
reasons,  so  that  the  details  for  guard  dutj  would 
always  leave  four  in  charge  of  the  tent. 

"Articles  wanted  for  a  mess  of  six:  Two 
champagne  baskets,  covered  with  coarse  canvas, 
with  two  leather  straps  with  truckles,  six  tin 
plates,  six  tin  cups,  >ix  knives  and  forks,  six 
bags  for  sugar,  ooffee,  salt,  etc.,  to  ln>|»l  from 
half  a  gallon  t<»  one  gallon,  one  large  size  camp 
kettle,  one  iron  pot,  one  bake-oven,  one  fryiug- 
]»;tn.  one  water-bucket,  one  lantern,  one  coffee- 
mill,  six  spoous,  one  tin  salt- box,  one  tin  pepper- 
box, two  butcher-knives,  two  kitchen-spoons, 
two  tin  dippers,  one  tea-pot,  one  coffee-kettle." 

It   is  always  a  good  rule  t<>  accustom  an  army 


SUGGESTIONS    FOR    A    MARCH.  4  7 

to  adopt  tlie  modes  of  living  common  to  the 
inhabitants  of  the  country  in  which  the  army  is 
found,  as  certain  peculiarities  of  living  naturally 
adapt  themselves  to  certain   climates. 

Although  war  brings  with  it  privations  and 
irregular  living,  which  it  is  impossible  to  pre- 
vent  the  mode  y)\'  Living  of  a  soldier,  to  a  cer- 
tain extent,  should  follow  a  fixed  standard.  His 
meals  should  be  equally  distributed  through  the 
day,  and  he  should  never  be  put  to  work  with- 
out having  broken  his  fast,  however  light  the 
meal  be.  If  this  lie  neglected  faintness  some- 
times ensues,  and  exertion  fails  from  mere  crav- 
ing of  the  stomach.  In  camp  soldiers  should 
live  with  regularity,  and  the  breakfast  and  din- 
ner hour  should  he  respected;  and  as  three  meaU 
a  dav  i>  the  custom  of  our  people,  this  regula- 
tion should  hi'  adopted.  It  is  on  the  march  that 
circumstances  prevent  the  carrying  out  of   rules. 

The  following  is  the  order  which  experience  has 
proved   t'»   he   most    useful    in    the    French   service. 

A  soldier  should  never  commence  a  march  with- 
out having  partaken  of  a  repast.  A  cup  of  hot 
coffee  with  bread  soaked  in  it  will  sustain  a  march 
of  tome  duration.      A   little   meat,  which  is  always 

saved  by  the  prudent  soldier  from   the  previous 
meal,  would  he  an  improvement!      for  night 


M  SI  i..,KV1!<i\s    FOR    A    MARCH. 

marching,  an  alcoholic  drink  after  the  meal  will 
enable  him  to  undergo  much  more  fatigue.  Pre- 
paratory i"  marching,  the  Boldier  fills  hi>  canteen 
wiili  good  water,  or,  whal  is  much  more  refresh- 
ing, weak  coffee  of  tea.  The  start,  especially  in 
summer,  should  always  be  at  the  break  of  day. 
After  marching  three-fourths  of  an  hour,  the  col- 
umn stops  tor  twenty  minutes.  In  resuming  the 
march,  a  halt  is  made  for  a  few  minutes  in  each 
hoar.  Fifteen  miles  a  day  is  considered  gooo" 
marching  tor  an  army,  ami  may  Ik-  divided  in  the 
following  order.  Nearly  three  miles  may  be  made 
during  the  first  hour  of  marching;  then  a  hall  is 
ordered  for  fifteen  minutes,  during  which  the  men 
should  remove  their  knapsacks  and  recline  upon 
tin-  ground,  as  standing  e-ives  but  little  relief. 
After  marching  for  three  or  four  hours,  a  halt 
should  be  ordered,  especially  in  summer,  until  the 

heat    of  the   day    passes,    when    the   march    may   he 

resumed.  During  the  midday  rest,  whilsl  dinner 
is  being  prepared,  if  any  opportunity  e\i>ts,  the 

shoes   and    Btoclrings   should    he    removed    and    the 

feet  bathed,  which,  by  removing  din  and  acid 
secretions,  will  prevent  excoriations.  It  may 
also   he   advantageous,  at    such  times,  to  change 

socks  from  one  foot  to  the  other,  so  thai  the 
seams  may  come   at    different    portions  ^i'  the  foot, 


SUOOESTION8    FOR    A    MARCH.  49 

which  will  prevent  continued  and  injurious  pres- 
sure. Soaping  the  sock  will  also  prevent  excori- 
ations, and  add  much  to  the  comfort  of  a  soldier 
whilst    on  a  march. 

In  crossing  a  ford,  the  men  take  oft'  their 
pantaloons,  keeping  on  their  shoes.  A  sentinel 
guards  any  fresh-water  spring  which  is  met  in 
the  march,  to  prevent  soldiers  from  gorging 
themselves  —  a  very  wise  measure,  which  pre- 
vents much  sickness.  An  aphorism  worthy  of 
remembrance  is —  Drink  always  before  marching, 
and  whilst  mi  the  match  meisten  the  mouth  often,  hut 
drink  seldom.  Water  should  always  be  taken  in 
reserve,  and  with  precaution.  When  taken  in 
great  quantities,  it  weakens  and  fatigues'  the 
organs  of  digestion,  increases  perspiration,  and 
enervates  the  entire  system.  It  is  particularly 
injurious  to  drink  rapidly  and  freely  when  heated 
m  exercise,  as  sudden  death  sometimes  follows 
this  imprudence. 

The  soldier  should  accustom  him&elf,  when 
thirsty,  to  drink  slowly  and  in  small  mouth- 
futs,  keeping  the  water  in  the  mouth  and  throat  . 
a<  long  as  possible.  The  cravings  of  thirsl  are 
often  produced  \>y  a  parched  condition  of  the 
lining  membrane  of  the  mouth;  and  by  rins- 
ing the  mouth  frequently,  thirst  can  be  allayed 
w5 


-I  UG1  ST10NS    FOR    A    MAI','  II 

to  such  a  degree  thai  l>ut  little  water  will  be 
required,  whilst  much,  hurriedly  drunk,  will  not 
satisfy  the  urgent  call.  In  marching,  thirst  can. 
in  a  measure,  be  prevented  by  keeping  the  mouth 
closed,  and  iii  speaking  as  seldom  as  possible; 
otherwise,  the  dry  air.  often  Loaded  with  dust, 
will  parch  the  lining  membrane  of  the  mouth — a 
very  distressing  sensation  when  it  cannol  be 
relieved  by  drinking.  Arabs,  in  crossing  Bandy 
deserts,  where  hut  little  water  can  be  found  to 
allay  the  intense  thirst  of  their  hot  climate,  adept 
the  wise  precaution  of  tying  a  handkerchief  over 
the  mouth,  which  keeps  out  dust,  and.  by  pre* 
venting  conversation,  prevent.-  to  a  great  extent 
thirst.      It  would  be  well  for  troop-  upon   a   march 

to  profit    by  their  experience. 

When,  during  a  march  or  halt,  the  fatigued  and 

thirsty  soldier  finds  water,  instead  of  rushing  to 
it  at  once,  he  should  first  try  and  repose  himself 
before  drinking;  then,  having  washed  out  his 
mouth  several  times,  drink  slowly  so  a>  to  make 
the  smallest  possible  quantity  of  water  supply  his 
-iii.-.  Washing  the  face  slackens  thirst. 
When  water  cannot  be  obtained,  a  bullet  or  peb- 
ble in  the  mouth,  or  chewing  a  green  leaf,  will 
cause  a  secretion  of  saliva,  and,  by  keeping  the 
oiith  moist,  will    temporarily   allay   thirst.    As 


SUGGESTIONS    COR    A    MARCH.  91 

good  water  is  not  always  to  be  obtained  on  a 
march,  a  soldier  should  never  lose  an  opportunity 

to  till  his  canteen  with  fresh  water.  If  the  can- 
beena  be  covered  with  a  light  colored  woollen 
cloth,  the  water  will  keep  cooler  than  in  bright 
(in.  which  absorbs  heal  more  rapidly,  and  ex- 
tends it  to  the  contents  of  the  canteen. 

Wften  troops  have  had  an  early  stai't.  they 
should  bivouac  about  ten  o'clock  in  the  morn- 
ing, and  lie  over  during  the  heat  of  the  day, 
as  loldiers  on  a  march  should,  if  possible,  be 
protected  from  the  midday  sun.  Here  they  will 
have  time  to  eook  their  midday  meal,  wash 
their  clothes,  and  refresh  themselves  from  their 
fatigue.  This  meal  consists  of  coffee  and  bread, 
with  meat  cooked  and  saved  from  the  preced- 
ing davs  repast.  'The  experienced  soldier  never 
forgets  t<>  keep  in  reserve  a  certain  proportion 
of  meal  or  other  food,  against  a  detieieiit  distri- 
bution or  the  want  of  time  for  properly  preparing 
il.  The  want  of  this  precaution,  which  old  sol- 
diers adopt,  is  severely  felt  by  l'ccrnits.  The 
meal  should  be  taken  iii  the  shade,  under  sonic 
protection  from  the  son.  A  few  branches  prop- 
erly  arranged,  will    form    a   comfortable   shelter. 

'flic    main    meal    of  meat,    vegetables,    etc.    should 

he  taken  after  the  evening  halt,  at  the  end  of  the 
days  march. 


Bfl  DAMPING    OF   TROOPS. 

The  officer  in  charge  of  the  troops  Bhould 
always  know  the  road  over  which  li«'  is  to  travel 
the  next  day,  and  when  he  is  compelled  to  bivouac 
in  places  where  the  prospect  for  getting  wood  fa 
bad,  each  soldier  should  carry  on  hi<  knapsack  a 
small  quantity  to  cook  his  midday  meal  with. 

When  troops  are  ordered  on  :i  forced  march, 
or  on  scoutiiiir  service,  their  food  should  be  pre- 
pared in  advance,  for  two  or  three  days  rations, 
or  they  Bhould  be  furnished  with  such  as  can  be 

rapidly  cooked  ;  sausage  or  meat  cakes  with  bis- 
cuit,   would    be    an    excellent     i  — lie    at    SUCH    tunes. 

In  the  evening  halt,  the  site  selected  tor  the 
camp,  when  possible,  Bhould  be  on  rising  ground, 
tree  from  low  places,  and  in  proximity  to  water 
and  wood.  These  rules  become  of  special  im- 
portance in  establishing  a  camp  for  even  a  few 
days  stay.     It  is  prudent  to  avoid  the  immediate 

vicinitj    of   swamp-    and     rivers:    the    emanations 

from  such  are  noxious,  often  pestilential,  Inn  for- 
tunately do  not  extend  to  a  great  distance.  In- 
terposing  a  piece  of  rising  ground  or  wood  i>.  as 

neral  rule,  sufficient  to  turn  <>r  break  Cur- 
rents from  these  low  places,  and  protect  from 
their  hurtful  influence.  It  would  lie  preferable 
to  camp  in  the  direction  of  the  regular  wind  cur- 
rents, so  that  emanations  may  he  wafted  in  the 
contrary   direction. 


CAMPING    OP   TROOPS.  f>3 

When   the    halt   is  only  for  the  night,  and  the 
camp  wagons  with  the  teats    have  not  come  up, 

the  men  bivouac  under  the  clear  sky,  Or  seek 
shelter  under  a  few  branches,  with  which  they 
form  a  rojagh  shed  that  will  protect  them  from 
dew.  If  possible,  dry  grass  or  leaves  form  their 
bed.  and.  lyin,g  in  their  great  coats  ami  upon  their 
india-rubber  cloths,  they  can  enjoy  peaceful  slum- 
ber. If  there  is  no  cover  for  the  men,  then  they 
build  tires,  and  sleep  around  these — lying  as  80 
many  radii  of  a  circle,  the  feet  o\'  the  sleepers 
being  nearest  to  the  tire.  Singular  to  say,  this 
kind  of  rough  life  <]oc^  not  bring  with  it  disease, 
as  one  would  suppose.  If  the  men  are  warmly 
clad,  they  enjoy  more  health  when  bivouacked 
than  when  under  tents.  Xo  troops  should  ever 
bivouac  upon  damp,  marshy  soil,  where  a  single 
nights  exposure  in  summer  would  poison  num- 
bers with  malaria,  or  in  winter  would  be  the 
fruitful  cause  of  pneumonia  or  rheumatic  affec- 
tions. 

The  site  of  a  permanent  camp  should  be  dry, 

with  good  drainage,  the  dryness  of  the  wJ  being 

•1  l>v  digging  thai  a  stratum  oi  water 

not  immediately  underlie  the  crust.     In  cold. 

damp  countries,  the   material   for  tents  should   be 

close,  ami.  as  nearly  as  possible,  waterproof; 


when  pitched,  a  good  ditch  should  be  dug  wound 
them,  with  the  earth  banked  up  against  the  tent 
to  keep  <>ut  the  CoH  ;m<l  rain,  and  also  to  pre- 
vent draughts.  When  troops  in  tin'  t  i  *  - 1  *  1  go  into 
winter  quarters,  it  is  eustomary  to  build  for  their 
protection  log  houses,  cabins  or  huts.  At  times, 
deep  holes  are  excavated,  and  roofed  over  with 
planking;  a  ditch  around  the  enclosure,  which 
should  be  always  deeper  than  the  excavation,  and 
filled  with  loos.-  stones,  will  keep  the  apartmenl 
i\\-y.  In  a  very  cold  climate  these  make,  per- 
haps, the  warmest  ami  most  comfortable  of  win- 
ter quart 

An  excellent  mod.-  of  making  a  tent  com- 
fortable iu  cold  weather  is  by  excavating  a 
basement   about    three    feel   deep,   which  will  at 

the   same   time   give    more    room,   and  permit    of  a 

stove  <>r  fire-place  in  the  centre  of  tin'  tent.  The 
dirt    from   within   should    he   hanked   up   against 

the  outer   side  of   the   tent,   to    keep   out    cold   and 

moisture.  Communicating  ditches  should  bepro- 
vided,  to  facilitate  drainage.  Of  tents,  the  cir- 
cular oil',  i-  the  best  protection  against  the  wind. 
is    least    liable   to   he  blown  down,  ami    is   most 

useful    for   winter. 

The  light  Bhelter-tent  of  the  French  troops,  as 

introduced    by    Marshal    Bugeaud,  will   he  found 


CAMPING    OF    TROOPS.  55 

most  convenient  for  the  summer  months  for 
an  army  in  the  field.  The  tent  is  made  of 
the  knapsack  of  the  soldier,  which,  instead 
of  being  sewed  up,  lias  its  sides  buttoned 
together.  When  unbuttoned,  it  is  a  square 
piece  of  cloth.  When  two  or  four  sacks  thus 
spread  open  are  buttoned  together,  and  the 
(Jentre  supported  by  two  sticks  three  feet  long, 
and  the  angles  staked  to  the  ground  by  small 
camp-pins,  the  two  or  four  persons  to  whom  the 
sacks  belong,  by  thus  joining  property,  have  a 
tent  that  will  keep  them  from  exposure  to  the 
sun.  and  also  protect  them  from  rain  or  dew. 
This  tent  is  not  more  than  three  feet  high  at  its 
ridge.  In  hot  and  dry  weather,  instead  of  pin- 
ning the  two  cuds  to  the  ground,  one  of  them 
can  be  hung  horizontally  to  branches  of  tree-. 
leaving  one  side  open  for  thorough  ventilation. 
whilst  the  horizontal  portion  protects  the  sleeper 
from  undue  exposure.  The  size  of  this  tenl 
can  he  increased  t<>  any  extent  by  joining  stock, 
as  all  sinh  sacks  are  of  the  same  size,  with  but- 
tons and  button  holes  arranged  equidistant. 

By  employing  this  excellent  suggestion,  you 
avoid  loading  the  shoulder.-  of  the  soldier,  or 
transporting  tents  for  the  army,  which  is  often 
impracticable.     In  a  few  minutes  after  fl  ball  tents 


56  camping  of   raoops. 

are  pitched,  and  the  camp  has  assumed  its  regu- 
lar appearance,  without  waiting  for  the  baggage 
train.  These  tents,  bo  convenient  and  always  at 
hand,  were  of  great  service  in  the  Crimea,  but 
particularly  in  Italy  in  1859,  whore  they  were 
the  sole  protection  for  the  troops. 

Rider's  tent  knapsack  is  made  as  follows:  It 
is  composed  of  a  piece  of  gutta-percha  cloth,  li\e 
feel  three  inches  lone  by  three  feel  eight  inches 
wide.  Two  of  the  borders  are  pierced  with  1  >ut- 
ton  holes  for  brass  studs,  a  third  border  has  a 
doubl  between  which  may  be  inserted  and 

buttoned  a  second  knapsack,  whilst  the  fourth 
edge  would  have  the  straps  and  buckles  neces- 
sary to  close  the  kuapsack.  The  weight  of 
the  gutta-percha  sheet  when  prepared,  is  three 
pounds.  The  additional  accoutrements  carried 
by   the   soldier    are   two    sticks,  three    feel  eight 

inches  long  and  one  and  a  quarter  thick,  which 
may    he    divided    in   the    middle,    with     the   pieces 

securely  attached  to  each  other  by  a  ferule; 
and  also  a  small  cord.  When  \\>v(\  a>  a  knap- 
sack, the  clothing  is  packed  in  a  bag,  and 
the  gutta-percha  is  folded  around  it,  lapping 
al  the  ends,  so  that  the  clothing  is  protected 
\>y  two  or  three  thicknesses  of  gutta-percha. 
Four   knapsacks   buttoned    together,  will   form   a 


SOLDIEa's   BKD.  •"'" 

sheet  ten  feet  six  inches  long  by  seven  feet  four 

inches  wide,  and  when  pitched  on  a  rope  three 
feet  four  indies  above  the  ground,  covers  an 
area  of  six  feet  six  inches  wide  by  seven  feet 
fonr  inches  long,  which  will  accommodate  five 
men.  and  may  be  made  to  give  shelter  to 
seven.  The  slieet  can  also  be  used  upon  the 
ground,  and  is  a  great  protection  against  damp- 
ness. 

The  soldier's  bed  should  never  be  directly  upon 
the  ground:  as  the  earth  always  contains  mois- 
ture enough  to  permeate  the  clothing,  and  rheu- 
matism, pleurisy,  pneumonia,  and  such  kindred 
affections  may  be  the  consequence.  It'  beds  can- 
not be  obtained,  branches  or  dried  leaves  or  straw 
should  be  used,  upon  which  the  blankets  are 
spread.  This  answers  the  double  purpose  of 
keeping  the  body  from  the  damp  ground  and 
of  elevating  it  into  a  layer  of  purer  air.  When 
the  tent  is  filled,  as  is  usually  the  case,  the  ex- 
haled air,  loaded  with  carbonic  acid  and  other 
impurities,  settles  to  the  ground,  which  persons 
Bleeping  upon  the  soil  would  be  continually  in- 
haling, to  their  injury. 

The  solder's  bed  should  be  always  dry.  All 
moi.-i,  decomposing  materials,  such  as  greeu 
grass   or   leaves,    are    more    injurious  than    sleep- 


I'll  H's    MED. 

ing  upon  the  soil,  owing  to  the  gases  escaping 
from  their  decomposition.  True  economy  would 
dictate  n  painted  cloth  for  the  floor  of  the  tent, 
which  rs  useful  in  preventing  the  exhalation  of 
moisture  from  the  earth's  Burface,  is  convenient, 
always  ready,  and  less  expensive  than  straw.  Ii 
can  be  cleaned  every  day  with  little  trouble, 
without  cost,  and  requires  to  be  freshly  painted 
only  once  a   year. 

When  straw  or  liav  is  used  for  bedding,  it 
should  be  renewed  as  frequently  as  possible,  and 
the  straw  should  be  turned,  well  beaten,  and 
thoroughly  aired  daily,  with  exposure  to  the  sun 
when  possible.  In  the  French  camp,  straw  is 
given  out  every  fifteen  "clays;  in  our  army  regula- 
tions twelve  pounds  is  allowed  per  month  in  bar- 
racks. As  a  soldier  always  sleeps  in  his  clothes,  if 
he  has  a  thick  bed  of  dry  straw  to  lie  on.  he  can 
cover  himself  with  his  blanket:  but  if  otherwise, 
lie  should  lie  on  his  blanket,  well  doubled,  i<> 
protect  him  from  the  damp  soil,  and  cover  with 
his  overcoat.     If  he   has  an    india-rubber   cloth, 

lie  should  always  lie  upon  it.  ;is  the  \i'\-y  I >«-| 
Use  he  .-an  make  of  it  to  protect  him  from  dis- 
ease. It  is  an  excellent  substitute  tor  straw  in 
field  lite,  more  cleanly,  and  protects  better  from 
dampness;   it    i-  always  at  Land  and  always  ready 


<M,KANl.rNKSS    OF    TAMPS.  59 

for  nee.  Sheep  skins  wore  tried  by  the  French 
;is  ;i  substitute  frbr  straw.  They  were  found  to 
attract  moisture  and  propagate  vermin,  and  were, 
therefore,   rejected. 

As  the  tent  is  always  too  small  for  the  num- 
number  which  Occupy  it.  the  inmates  should 
Bleep  with  their  heads  as  far  as  possible  from 
each  other.  In  the  circular  tent,  they  should 
sleep  with  their  feet  toward  the  vertical  axis. 
and  their  heads  around  the  periphery,  so  as  to 
increase  to  the  utmost  their  respective  areas  for 
respiration.  After  reveille,  the  tents  should  he 
opened,  sides  thoroughly  beaten,  straw  turned, 
and  exposed  for  several  hours. 

Extreme  cleanliness  should  -prevail  within  and 
without  the  tent.  In  an  encampment,  the  tents 
should  never  he  crowded,  hut  ample  space  should 
he  ld't  around  each  lent  I'm  changing  its 
tion  ;it  le.-ist  every  four  days,  so  as  to  purity  the 
soil  infected  by  habitation.  The  earth  floor  ^\' 
a  tent  attracts  and  absorbs  impurities  which, 
unless  changed,  would  soon  render  it  a  source 
of  disease.  Permanence  of  camps  rapidly  in- 
duces infection.  This  frequenl  changing  of  tents 
gives,  to  he  sure,  additional  trouble  to  the  offi- 
cers, hut  this  i-  more  than  counterbalanced  by 
the  health  and  efficiency  of  the  command.      All 


(ill  :    tNLlNBSS    "l     'AMI'S. 

the  prarbagi    of  the  camp  should  be  thrown  :»t  a 
distauce    from    1 1n-    tents,  and    should    be  buried 
\    evening. 
The    privies    for    the    men    are   ditches,    from 

to  five  feel  deep  and  three  feel  broad, 
and  screened  from  view  by  branches  stuck  in 
the  earth.  These  privies  or  latrines  should  be 
dug  narrow  and  deep,  so  as  to  leave  as  little 
space  as  possible  for  evaporation.  The  com- 
mon laws  of  hygiene  insist  that  these  be  pre- 
pared immediately  upon  the  establishment  of 
an  encampment,  and  that  the  meu  be  compelled 
to  use  them  under  a  penalty.  The  want  of  these 
and  the  uegligence  in  insisting  upon  their  being 

may  be  considered  one  of  the  duel  causes 
of  the  fearful  amount  of  sickness  whicb  diffused 
itself  this  past  summer  over  our  armies  in  Vir- 
ginia. Gentlemen  who  composed  our  voluuteer 
regiments  would  not  be  ordered  to  these  ditches, 
and  as  the  officers  did  not  insist  upon  what  the 
men  objected  to  as  unnecessarily  troublesome^ 
the  result  was  that,  with  hut  few  exceptions,  our 
regimeutal  camps  were  accumulations  of  filth  of 

description,  which  could  be  smelt  at  a  dis- 
tance whilst  approaching  them.  It  was  not  >ni'- 
prisiug  that  disease  and  death  followed  in  the 
wake  of  sucb  indifference  to  all  laws  of  decency 
and  hygiene. 


CLKANMNESS    OF    CAMPS.  '*»  I 

The  privies  should  be  placed  at  least  one 
hundred  yards  from  the  tents,  and  in  an  oppo- 
site direction  to  the  wind  currents,  so  that  offen- 
sive odors  will  be  blown  away.  The  slaughter 
pens  should  also  be  placed  at  a  similar  distance. 
Every  evening  the  oftal  of  the  day  should  be 
covered  with  three  or  four  inches  of  earth,  or 
a  sufficient  layer  to  prevent  any  smell  arising 
from  the  davs  deposit.  When  the  trench  is 
two-thirds  full,  it  should  be  closed  and  another 
of  similar  dimensions  opened.  Where  proximi- 
ty to  the  water  permits,  these  privies  should  be 
established  over  the  water.  This  will  remove  a 
greai  and  common  source  of  infection,  which  is 
very  difficult  to  counteract. 

In  permanent  camps,  dead  animals,  horse 
dung,  and  all  animal  refuse,  should  also  be  bur- 
ied, otherwise  the  stench  from  them  would  be 
wvy  injurious  to  the  health  of  the  troops.  Bu1 
;.-.  notwithstanding  the  utmost  care,  in  the  most 
salubrious  situations,  diseases  will  in  time  show 
themselves — from  the  inevitable  accumulation  of 
poisonous  materials,  resulting  from  the  growing 
infection  of  the  soil,  with  it-  poisonous  emana- 
tion-, from  the  prolonged  sojourn  of  a  Large 
number  of  men  ami  animals — the  camp,  anless 
occupying  a  position  of  marked   military  impor- 


AM  ,;    -«.|.!.IKli>. 

y 
tauce,  should  be  changed   for  u  new  situation  at 
>« »inc   «i'n\ iii'n'iit    distance. 

For  i  permanent  camp,  board  huts  are  much 
more  comfortable  and  healthy  for  troops,  whilst 
for  transient  halts  a  shelter  composed  of  brauch- 
i n mli  more  desirable  than  tents.  Troops 
bivouacked  are  always  more  healthy  than  those 
regularly  under  shelter.  It  is  well  known  that 
irregular  troops,  which  ad  in  the  advance  lino 
of  armies,  and  which  have  no  other  shelter  from 
the  weather  than  a  tree,  rarely  experience  sick- 
; — never  at  least  the  sickness  which  proceeds 
from  contagion,  an  evil  contingent  to  camps. 
One  great  advantage  of  using   huts  is.  that  they 

an-    left    behind    with     the     infectious    air     which 

might  have  been  generated  within    them,  whilst 
the  same  contagion  is  often  transported  with  the 

tents. 

A-  the  daily  drills  do  not  suffice  to  develop 
the  physical  organization  of  the  soldier,  he  might 
i>e  usefully  employed  upon  public  work.-,  which 
may  revert  to  his  individual  benefit,  as  the  mak- 
ing of  military  roads,  draining  the  sites  <<\  camps, 
etc.  For  months  the  roads  in  the  vicinity  of 
Manassas,  where  the  army  of  the  Potomac  were 
stationed,  were  nearly  impassable,  and  transpor- 
tation was  so  exceedingly  difficult,  that  the  army 


AMI  SKMKNTS    FOB    SOUUKRs.  G3 

suffered  severely  for  properfoed.  Had  the  troops 
been  ordered  to  work  the  roads  instead  of  loit- 
ering tor  months  in  camp,  the  service  would 
have  been  materially  advanced. 

To  enliven  and  relieve  the  toil  and  tedium  of 
camp  lite,  amusements  are  a  very  necessary  por- 
tion of  the  davs  duties;  and  it  is  found  that 
lively  music  from  the  military  Viands  every  af- 
ternoon, will  elate  the  men  and  remove  monoto- 
ny. Singing  and  music  should  be  a  portion  ^\' 
the  military  education,  as  offering  an  agreeable 
mode  of  passing  the  many  idle  hours  of  camp 
life  which  usually  hang  so  heavily  upon  the  sol- 
dier. Temporary  gymnasia  might  be  established, 
and  gymnastic  exercises  should  be  encouraged  as 
conducive  to  health,  strength,  agility  and  address. 
Playing  hall,  rolling  ten  pins,  shooting  marbles, 
throwing  quoits,  racing,  wrestling,  are  all  pre- 
ferable to  oard-playing,  which  in  camp  is  Lnsep- 
erable  from  gambling.  In  the  summer  of  1869, 
during  the  Italian  campaign,  I  was  at  Milan, 
when  a  large  body  of  French  troops,  returning 
from  the  bloody  field  of  Sol&rino,  arrived.  In 
a  tew  minutes  their  shelter-tents  were  pitched, 
under  the  shade  of  the  tires  on  the  broad  bou- 
levard which  surrounds  the  city,  and  the  sol- 
diers were    allowed    to    follow  the    bent   of   their 


04  \Mi  -kmi:\  n    Lilt    SOLDIERS. 

own  inclination.  Card-playing,  dominoes,  for- 
tune-telling, wrestling,  and  dancing  to  the  dis- 
cordanf  tunes  of  :t  band  organ,  or  the  sharp 
notes  of  an  accordeon^  appeared  t<>  Ik-  the  order 

of  the  <lav. 

Pets  in  various  forms  were  commonly  found 
among  the  troops,  and  these  were  guarded  with 
scrupulous  care.  Many  appeared  to  lie  adopted 
l>v  the  regimenl  as  comrades,  who  have  been 
associated  together  through  many  a  hard-fought 
field  and  toilsome  inareli.  In  the  military  hos- 
pital- of  Milan — which  were  filled  with  the 
wounded,  from  its  very  near  proximity  to  the 
battle  field  and  railroad  facilities  lor  transporta- 
tion— it  was  not  unusual  to  see  a  Boldier,  nearly 
exhausted  from  the  tedious  dressing  of  a  fright- 
ful wound,  when  he  had  passed  from  the  hands 
of  the  surgeon,  take  from  his  boso/n  a  Tittle  spar- 
row, and  from  the  cheerful  chirp  of  this  little 
bird  appear  to  derive  much  consolation. 

Not     the    least    attractive    incident    connected 

with  the  triumphal  march  of  Napoleon's  Italian 
army  through  Paris,  in  August,  1859,  was  the 
pet-  accompanying  these  brave  heroes.  Here 
would  he  seen  a  -oat.  evidently  proud  of  its  po- 
sition, marching  with  military  Step  at  the  head 
of  a  column  of  ferocious  Zouave-:  going  through 


AMUSEMKNTS    FOR    SOLDIERS.  65 

the  halt  and  advance  by  word  of  command,  look- 
ing neither  to  the  rigid  or  left,  as  if  the  success 
of  the  day  depended  upon  its  military  deport- 
ment. Here,  a  regimental  dog  would  show  the 
pleasure  with  which  he  participated  in  this  great 
occasion,  whilst  the  caresses  of  the  company  and 
the  pleasant  faces  with  which  his  presence  would 
always  be  recognized,  show  the  appreciation  of 
his  companionship.  These  little  incidents  are 
introduced  to  show  the  longing  of  all  men  for 
Objects  of  affection,  and  also  how  many  a  tedi- 
ous and  otherwise  unbearable  hour  in  camp  life 
is  pleasantly  spent  in  fostering  those  fine  feel- 
ings of  the  human  heart,  which  keep  soldiers 
accustomed  to  hlood,  from  becoming  degraded 
and   brutal. 


c  II  A  PT  E  R    11. 

Hospitals,  Regimental  <m<l  General — Hospital  Tents, 
witii  Equipment — Number  of  Attendants  nl/>-ir,il — 
( ',!,••  necessary  in  preventing  Infection — Vahm  a/ 
Fumigation — FemaJk  Attendants — Hospital  Db 

The  accommodations  for  the  Bick  form  a  very 
important  departmenl  in  the  economy  ef  an 
army,  and,  as  a  rule,  are  never  sufficiently  am- 
ple*       With     even      bodj    Of    trOOpS,    ill     the     field, 

there  are  two  kinds  of  hospitals — the  regimental 
and    the    general.     With    regular   armies,    there 

should  always  he  a  third — the  convalescent  hos- 
pital— situated    in   BOme  BalubrioUB,   rural   location, 

where  convalescents,  by  inhaling  pure  air.  and 
enjoying  the  pleasures  of  country  life,  ran  rap- 
idly rebuild  their  shattered  constitutions. 

For  the  army  in  Virginia  during  the  slimmer 
and  autumn  of  1861,  convalescent  hospitals  were 
established  at  points  well  adapted  for  the  | »ur- 
pose,  and  wviv  of  essential  benefit.  The  Vir- 
ginia springs  are  known  to  all  the  world;  at 
such  places  <>\'  resort,  every  convenience  exists 
for  accommodating  large  numbers  of  visitors. 
At  some  of  these  watering  places,  the  hotels  and 


REGIMKNTAL    HOSPITALS.  67 

numerous  cottages  were  converted  into  extensive 
hospitals,  where  convalescents  from  the  measles 
ami  typhoid  fever  could  use  the  mineral  waters, 
enjoy  the  fine  scenery,  and  recruit  rapidly. 

The  REGIMENTAL  hospital  is  usually  under  tents 
when  in  the  field,  if  a  suitable  building  in  the 
immediate  vicinity  of  the  encampment  cannot  be 
obtained.  The  tents  used  as  hospitals  in  the 
Confederate  service  are  fourteen  feet  in  length, 
fifteen  feet  wide,  and  eleven  feet  high  in  the 
centre,  with  a  wall  four  and  a  half  feet,  and  a 
kk  fly "  of  appropriate  size.  The  ridge  pole  is 
made  in  two  sections,  measuring  fourteen  feet 
when  joined.  On  one  end  of  the  tent  is  a  lapel, 
which  admits  of  two  or  more  tents  being  joined 
or  thrown  into  one.  with  a  continuous  covering 
or  roof;  such  a  tent  accommodates,  comfortably, 
From  eight  to  ten  patients.  The  following  is  the 
allowance  of  tents  lor  the  sick,  their  attendants 
and  hospital  supplies — being  accommodation  for 
ten  per  cent,  of  the  command  : 


■ospn  \i   ii  m i. 

COM  WO* 

III  V  .    .    . 

Fur  three  companies . 

i           .  •  n  compani<  - . 

i 

2 

:: 

1 
1 
1 
l 
1 

1 

1 
1 
1 
1 

<i^  HK.oiVKNTAl.    HOSfrlTAT.S. 

Only  those  cases  which  promise  to  be  transi- 
ent indispositions  <>r  acute  diseases  are  retained 
for  treatment  in  the  regimental  hospitals.  Thcv 
are  temporary  structures,  to  be  moved  with  the 
army  and  M  be  broken  up  at  an  hours  notice. 
They  should  never,  therefore,  be  encumbered 
with  chronic  cases,  nor  should  they  ever  be  per-, 
niitted  to  be  crowded.  As  soon  as  a  case  threat- 
ens to  remain  longer  than  a  few  days  in  hos- 
pital, it  Bhould  he  transferred  to  tin-  general 
hospital  for  treatment. 

To  ensure  a  comfortable  abode  lor  the  sick, 
the    site    of  the    regimental    hospital    Bhould    be 

selected  with  much  care — the  driest  spot  in  the 
Camp     should      he      chosen,     and     the      tent      well 

ditched   to   give    thorough    drainage.      The  floor 

of  the  tent  should  he  carpeted  with  oil  floor- 
cloth or  painted  canvas,  which  will  protect  the 
sick  from  the  emanations  from  the  soil,  and 
will  prevent  the  soil  from  imbibing  animal  efflu- 
via. It  also  keeps  out  all  moisture,  which  is  9Q 
deleterious     to     those     lying     upon     the     ground. 

This  painted  cloth  strictly  belongs  to  the  hos- 
pital tent,  and.  as  an  essential  part,  should  never 
be  overlooked.  A  certain  number  of  bed-sacks 
also  belong  to  the  hospital.  When  these  are 
filled  with   straw,  they  make  a  much  more  com- 


REGIMENTAL    HOSPITALS.  69 

Portable  bed  than  straw  thrown  in  heaps,  Which 
is  the  common  mode  of  treating  the  sick  in  the 
field.     There    is    much    comfort    in   appearances, 

and  these  beds  add  nincli  to  the  neatness  as 
well  as  cleanliness  of  the  tent.  The  beds  fere 
arranged  on  either  side  of  the  tent,  with  the 
heads  turned  toward  the  wall.  Could  the  beds 
!>■'  elevated  upon  hoards  tor  six  or  twelve  inches, 
they  would  place  the  sick  in  a  purer  atmos- 
phere than  when  lying  on  the  floor,  where  the 
heavy,  deleterious  <^ases  of  expiration  collect.  In 
Lr<>od  weather,  ventilation  of  these  tents  should 
always  he  insisted  upon.  When  the  painted 
*  floor-cloth  is  not  at  hand,  the  earthen  floor 
should  he  well  rammed,  and  should  be  daily 
Watered  with   a   milkv  lime-water  as  a   purifier. 

The  straw  should  hi'  changed  as  often  as  pos- 
sihle.  even  twice  a  week,  if  it  can  be  procured  J 
whilst,  if  the  patient  can  get  up,  the  bed  should 
be  well  beaten  and  thoroughly  aired  daily.  /'  r- 
snicil  eleanUness  of  the  "patient  is  as  important  as 
thai  of  the  tent.  Ablutions  must  be  freely  used, 
and  under-clothing  frequently  changed.  When- 
ever the  patients  permit,  the  tent  Bnould  he 
moved  once  a  week,  if  it  be  only  a  few  yards 
from  it-  former  position,  so  as  to  enclose  a  fresh 
pier.-  of  rM.il    not  con  t  a  mi  ii  afed  with  animal   exha- 


70  UKOIMIMAI,    HOSPITALS. 

lations.  This  change  c€  location  is  particularly 
required  whenever  any  of  the  low  grades  of  con- 
tagious diseases  appear  within  it-  wail>.  or  em 

under   treatment   take    OB   an    astha-nic    characfc t. 

The  hospital  is  allowed   a  pertain   number  of 

attendant-,    to     attend     to     tne     commissary     ami 

medical  duties  of  the  establishment.  Each  com- 
pany has  one  steward,  one  nurse,  and  one 
cook;  for  eaeh  additional  company,  one  inn 
is  added  ;  and,  for  commands  of  over  live  com- 
panies, one  additional  cook.  The  surgeon  is 
general  superintendent  of  the  hospital,  rnilcr 
his  direction  the  steward  takes  care  of  the  hos- 
pital stores  and  supplies,  and  sees  that  the  » 
nurses  ami  cooks  perform  properly  their  respec- 
tive duties;  and  often  he  al-o  acts  as  medical 
dispenser  and  apothecary  to  the  regimental  hos- 
pital,    li'  intelligent,  he  can   readily  he  instructed 

in  the  preparation  of  prescriptions  for  the  sick, 

and  relieve  the  surgeon  of  this  trouble. 

Not  the  least  important  personage  in  the  hos- 
pital organization  is  the  sentinel,  who  guards  the 
door    and    sees   that    neither    ingress   nor  egros   if 

permitted   except  upon  orders  from  the  surgeon. 

It  is  onlv  in  this  way  that  patients  can  he  pre- 
vented from  committing  imprudences  which  may 
cost    them    their    lives.      This   guard    should    be 


GENERAL    HOSPITALS.  *  L 

constantly  furnished  to  the  hospital,  and  the  sur- 
geon is  to  signify  to  the  commanding  officer  0$ 
the  regiment  the  particular  orders  which  he 
wishes  to  he  given  to  the  non-commissioned 
officer  commanding  it  and  to  the  sentries. 

Those  treated  in  a  tent  hospital  always  conva- 
lesce much  more  rapidly  than  those  collected 
together  in  a  large  hospital  building,  where,  in 
proportion  to  the  magnitude  of  the  establish- 
ment and  number  of  patients,  we  find  the  con- 
valeseence  of  the  siek  prolonged,  the  nnmher  of 
deaths  increased,  and  the  germs  of  contagious 
diseases  developed.  In  concentrating  a  number 
*  of  sick  under  one  roof,  the  laws  of  hygiene 
will  he  violated  —  it  cannot  he  avoided.  Yet, 
from  the  very  transient  nature  of  regimental 
hospitals,  more  permanent  institutions  for  the 
siek  must  he  established. 

The  general  hospital,  for  the  use  of  a  division 
of  the  army,  is  usually  located  in  some  town  or 
city  contiguous  to  the  army  ;  or,  should  these 
be  too  distant,  without  facilities  of  transporta- 
tion, some  building.-  are  take  possession  of  near 
tbe  lines  and  converted  into  a  hospital.  Tbe 
organization  of  tbis,  with  its  surgical  staff,  its 
steward,  ward-master  and  nurses,  is  upon  a  much 
larger    scale.       Ordinarily,  tlic   following    hospital 


fA  01  M  B  \1.    HO8MTAL8. 

attendants  are  allowed:  A  Rteward,  a  ward-mas- 
ter, an  orderly  (taken  from  the  ranks)  to  act  as 
rttrree  for  every  ten  sick,  a  laundress  for  every 
twenty,  and  one  cook  to  every  thirty  patients'. 
-Each  nurse  is  made  responsible  for  cleaning 
and   taking  care  of  ten  beds,   with  the  floor  and 

utensils    included    in    the    spac< cupied    by  the 

ten  beds.  His  duty  includes  bringing  t«>  the 
ward  and  distributing  to  the  patients  the  daily 
rations,  and  also  the  medicines  prescribed  at  tbe 
visit.  The  cooks  and  nurses  are  taken  from 
tlie  rank'-,  and  are  returned  when  no  longer  re- 
quired in  the  hospital.  In  a  general  hospital,, 
there  is  always  a  dispensing  officer  or  apothe- 
cary, who  prepares  the  (prescriptions  of  the  sur- 
ui.  and  delivers  the  same  to  the  nurses  upon 
application  at  the  dispensary.  In  regimental 
hospitals,  the  surgeon,  or  Ins  assistant,  when 
present,  perforate  this  duty,  if  an  intelligent 
-teward  has  Bo1  been  instructed  by  the  Burgeon 
in  preparing  medical  prescriptions.  In  a  large 
general  hospital,  the  steward  represents  the  com- 
missary department.  Wnoever  attends  to  the 
pharmaceutical   department   should  be  careful   to 

keep  all  poisonous  drugs  under  key.  so  that  no 
accident  mighl  occur  to  the  inmates  of  the 
hospital,  whether  by  design  or  through   mistake. 


( I.KANSINC     UF     IIOSI'ITAI.S.  73 

In  his  general  1  n > ^ [ » i t ; 1 1  we  have  (tegular 
wards,  whicb  are  always  objectionable  from  the 
numhcr  of  s'u-k  crowded  into  these  compart- 
DH'iits.  Every  bed  for  a  patient  should  liave  a 
certain  number  of  cubic  feet,  or,  as  height  docs 
not  compensate  for  area — as  all  the  dangerous 
gases  stagnate  in  the  lower  strata — it  would  be 
better  to  allow  each  patient  so  many  square 
feet — say  fifty  square  feet  for  each  bed.  For 
those  who  are  severely  wounded,  or  sick  with 
typhus,  twice  this  area,  or  one  hundred  square 
feet,  will  not  be  too  much  space,  if  it  be  de- 
sirable to  prevent  pyaemia,  hospital  pina'mii'. 
erysipelas,  and  other  fatal  complications,  from 
showing  themselves*  Rooms  with  less  than 
ten  feet  ceiling,  are  not  fit  accommodation  for 
the  sick.  With  the  constant  tendency  to  a 
poisoning  of  the  atmosphere  from  imperfect 
ventilation,  all  precautions  of  cleanliness  cannot 
be  too  rigidly   enforced. 

In  the  cleansing  of  hospitals,  too  frequent 
scouring  is  prejudicial  to  the  sick  and  is  found 
to  induce  low  forms  of  disease.  In  Fiviieh  bo* 
jiitals.  the  wooden  floors  are  waxed  and  rubbed 
daily,  which  avoids  the  excess  of  moisture  in 
the  atmosphere  of  a  ward.  In  military  hospitals 
it  would  be  better  to  sand  the  floors  daily,  wash- 
7 


(4  rxEANsixn   of  hospitals. 

ing  only  tin'  very  dirty  spots.  Spittoons  should 
he  furnished  to  every  bed,  and  the  nek  should 
he  prohibited  1V« nn  spitting  upon  the  floors. 
The-e  spittoons  -hould  be  cleansed  daily,  and 
newly  sanded;  and  when  much  used,  the  sand 
should  be  changed  twice  daily,  or  they  become 
offensive  and  injurious.  All  urinals,  bed-pans, 
or  chamber-pots  should  he  emptied  as  soon  at 
used,  and  never  be  allowed  to  remain  soiled  in 
the  ward.  The  hunks  in  the  hospital  after  being 
in  use  for  three  or  four  weeks,  should  he  taken 
out  of  the  wards,  well  scoured,  and  exposed  to 
the  weather,  before  they  are  returned.  As  soon 
as  a  bed  is  vacated,  if  it  has  been  in  use  more 
than  ten  or  fifteen  days,  the  straw  should  he 
burnt  and  the  sac  washed  and  refilled.  Blankets 
should  also  he  frequently  efeanged  and  washed. 
Personal  cleanliness  is  essential  in  a  general  hos- 
pital. If  conveniences  are  at  hand  the  patient, 
upon  admission,  should  he  bathed,  and  placed 
in  clean  clothes,  and  in  a  clean  bed.  The  heds 
should  always  he  kept  in  order,  whether  occu- 
pied or  not,  and  should  a  patient  leave  it  only 
tor  a  few  minutes,  it  should  he  put  in  order 
whilst   he   is  out   of  it. 

Such   a   general    hospital    should,   among  other 
things,  be  liberally  furnished  with  hospital  cloth- 


CLPANS1NO    OP    HOSPITALS.  75 

ing.  In  European  general  military  hospitals,  the 
patient  leaves  everything  behind  him  when  lie 
enters  its  wards.  lie  receives  a  bath,  and  is 
dressed  up  in  the  hospital  elothes;  his  own  are 
washed  and  stowed  away,  properly  lahelled  by 
the  ward-master.  Should  lie  lie  suffering  under 
any  contagions  disease,  as  the  itch,  typhus  fever*, 
etc.,  his  clothing,  alter  being  well  beaten  and 
washed  in  boiling  water,  are  fumigated  for  twen- 
ty-four hours  in  a  closed  chamber  or  tent  with 
chlorine  gas.  With  itch  patients,  sulphur  fumi- 
gations  are    substituted    for  chlorine. 

The  ward-master  should  never  allow  the  wards 
of  a  hospital  to  lie  encumbered  with  the  pack- 
ages or  accoutrements  of  the  inmates,  but  all 
such  should  he  stored  away  in  a  store-room, 
where  a  series  of  pigeon  holes,  two  feet  square, 
are  arranged,  and  numbered  as  are  the  beds,  so 
that  each  inmate  of  the  hospital  has  a  square 
allotted  to  him,  wherein  to  deposit  his  private 
stores.  Where  the  hospital  is  well  organised, 
every  article  which  the  patient  brings  in  is  de- 
posited in  the  storr-room.  as  he  is  expected  to 
be  supplied   from  the   hospital   wardrobe. 

Whenever  an  intentions  or  contagious  epidemic 

threatens  to  Invade  an  hospital,  the  sanitary  po- 
lice of  the  institution   should   redouble  their  vigil- 


,  0  PI  HIIK'AI  ION     01     llnsl'll  Al  ,8. 

Alice  to  eemove  <>r  counteract  those  aausee  which 
might  assiei  in  produciug  or  disseminating  such 
disease.     A    thorough   examination  of  the   build* 

in--  >]icul<l  be  made;  ail  offal,  of  whatever  char- 
acter, should  he  immediately  removed  a-  soon 
as  discovered.  This  relates  especially  to  the 
using  of  chamber  utensils  in  the  wards,  which, 
udder  no  circumstances,  should  Ik-  allowed  to 
remain  soiled.  Cleanliness  in  every  department 
must  be  enjoined.  The  diet  of  the  patients 
.should  la-  improved  in  quality,  ami  more  liber- 
ally distributed;  ftud  wine,  or  some  stimulating 
drink,  should  ho  given  to  convalescents,  who 
should  la  examined  daily,  that  any  irregularity 
in  their  digestive  apparatus  may  be  corrected. 
Free  ventilation  of  the  building,  the  frequent 
changing  of  bedding,  avoidance  of  all  crowding 
in  the  ward,  and  an  increase  in  the  U umber  of 
cubic  feet  to  each  patient,  the  separation  ol'  con- 
valescents who  should  he  sent  away  from  the 
infected    building,    the    early     burial    of    the   dead, 

both  lor  iis  moral  as  well  as  hygienic  benefit^ 
arc  -nine  of  the  precautions  which  surgeons  in 
charge  of  hospitals  will   adopt. 

When  any  low  form  of  disease  makes  its  ap- 
pearance in  a  ward,  it  would  lie  better  could  it 
he  temporarily  abandoned.     Then  let  it  undergo 


1  ;   r.U'R'ATMX    OF    UOSITIWT.S.  77 

a  thorough  cleansing  and  whitewashing,  with 
fumigations  of  chlorine.  Heating  the  air  con- 
tained within  the  closed  room  by  mean*  of 
stoves,  so  as  to  attain  a  high  temperature,  nun 
destroy  the  fomites  causing  the  disease,  and  ren- 
der die  ward  again  habitahle.  This  course  should 
also  be  adopted  whenever  a  ward  has  been  occu- 
pied by  the  seriously  injured,  with  extensively 
suppurating  wounds.  Should  any  one  enter,  at 
midnight,  a  ward  thus  inhabited,  the  insufferable 
smell,  and  the  apparent  weight  of  the  atmosphere, 
would  at  once  explain  the  danger  of  infectious 
diseases  and  the  necessity  for  not  only  constant 
cleanliness  and  continued  ventilation,  hut  :\\>^ 
for  purifying  the  same  at  intervals.  Such  rooms, 
ii  ia  said,  should  he  thrown  out  of  use  for  two 
weeks  after  every  two  months  occupation.  This 
is  laid  down  as  an  important  hospital  regulation 
by  Stromyer,  in  his  Maxims  of  Military  Surgery, 
based  upon  experience  and  observation  during 
the  Schleswig-Holstein  war.  Chemical  disinfect- 
ants  were  not  found  useful  by  him  when  the 
rooms  were  occupied;  the  rooms  must  he  empty. 
F<,r  weeuepied  rooms,  draughts  of  fresh  air  arc  the 
enly  good  disinfectants,  and  to  obtain  this  end. 
without  detriment  to  tin-  sick:,  the  windowe 
should     open    mar    the    ceiling,    and     the    sashe* 


7^  PlTfclFICATJOW    •'»'    HOSPITALS. 

sin >ul<l  !»»•  so  arranged  that  the  apper  one  can 
he  lowered,  which  admita  fresh  air  without  pour- 
hie  a  cun»nt  of  air  directly  u ] >< >ti  the  si<-k.  The 
slight  exposure  t<>  catarrhal  affections  i>  n<>t  to 
be  considered,  when  compared  to  the  danger  of 
introducing  infectious  diseases,  by  permitting  a 
foal  and  unrenewed  atmosphere  t<>  be  inhaled 
by  the  wounded.  It  is  owing  to  the  advantages 
of  ventilation,  that  tents  are  so  much  better  for 
typhus  and  severely  wounded  patients  than  wards. 
Pure  air,  continually  renewed,  is  essential  for 
the  curt'  of  typhus.  Abundance  of  fresh  air  covers 
a  multitude  of  inconveniences.  In  the  Crimean 
service,  the  French  attached  great  importance  be 
the  fumigation  <>l'  their  wards.  The  surgeons  of 
their  immense  military  hospitals  thought  thai 
they  derived  decided  benefit  from  adopting  the 
Turkish  custom  of  fumigating  with  dried  sage1 
which  was  Inirnt  in  the  wards  three  times  u 
day,  besides  the  use  of  chlorine  fumigations 
morning  and  evening. 

loudens  states  that,  by  using  chlorine  fumi- 
gations al  6,  \.  .M..  and  at  7,  P.  M.,  the  dried 
sage  at  7.'..  \.  M.,  1.  i\  m..  and  8$,  p.  ML,  lie 
succeeded  in  preventing  as  well  as  stopping  in- 
fectious disorders.  A  saucer  of  chloride  of  lime 
was  also  placed    under   the   bed  of  each    typhus 


PURIFICATION    Of    HOSPITALS.  ft 

patient.  It  is  a  question  whether  these  fu  mi  sta- 
tions act  from  the  medicinal  virtues  which  they 
possess,  or  upon  hygienic  principles.  The  Eu- 
ropean nations  have  such  a  dread  of  draughts, 
that  a  door  or  window  is  never  left  open*  ^Y<• 
would  judge  that  they  were  intended  to  give 
light,  and  nol  air.  The  only  way  in  whirl)  such 
herb  fumigations  can  be  of  use.  is  to  make  the 
atmosphere  so  disagreeable  thai  all  the  windows 
must  he  thrown  ope*  to  s;-et  rid  of  it.  As  it 
escapes  from  these  openings,  fresh  air  equally 
rushes  in   to  purity   the  room. 

This  difficulty  of  ventilation  through  the  win- 
dows, which  are  the  proper  media  for  it.  is  the 
common  subject  of  complaint  aniono-  the  medi- 
cal staff*  of  the  hospitals.  Stromyer  had  to  enter 
into  a  regular  compact  with  his  German  pa- 
tients, lie  would  only  allow  them  to  smoke  pro- 
vided  they  would    keep   the  windows   open,   using 

this  subterfuge  to  ventilate  the  wards.  A  cele- 
brated English  medical  lecturer  placed  the  value 
of  fumigations  in  their  true  light,  when  he  said 
"fumigations  are  of  essential  importances  they  m<il,< 
such  "a  abominabU  sun  II  that  they  compel  ;/0U  to 
,,/},!,  the  windows."  When  these  means  are  used, 
without  affording  the  impure  air  means  of  es- 
cape,   they    onk     ad     as     masks:    disguising,    by 


v   I  II   RIFICATIO.N    OF    HOSPITALS. 

their  strong  odors,  the  offensive  and  injurious 
exhalations  from  the  sick.  They  quid  the  anxie- 
ties <>f  llic  nurse,  without  in  any  way  benefiting 
the   patient. 

It  must  never  be  forgotten  thai  many  Bymp- 
totns  which  are  said  to  belong  to  a  disease,  de- 
pend upon  tin*  cirenm8tances  under  which  it 
is  treated,  and  many  of  these  can  with  truth 
be  accredited  to  bad  ventilation  ;  hence  the  dif- 
ferent phases  Which  diseases  assume  when  treat- 
ed in  hospitals  or  in  private  practice.  If  Buch 
causes  will  produce  disease  (a  fact  with  which 
every  one  is  familiar),  how  much  more  likely 
are  they  to  modify  those  already  existing.  Every 
physician  of  experience  and  observation  has  seen 
serious  cases  of  fever,  threatening  a  fatal  issue, 
commence  to  improve  from  the  moment  that 
the  patient  was  changed  from  the  room  in  which 
he  had  long  heen  lying,  with  its  closed  windows 
and  otnsty  smell,  to  a  light,  cheerful,  well-ven- 
tilated chamber.  This  is  always  attributed  to 
change  of  Beene,  whilst  the  true  cause,  change 
of  air,   is  overlooked. 

Typhus  cases  particularly,  should,  if  possible, 
be  isolated  in  tents,  and  ample  room  be  given 
to  eaeh.  Over-crowding  is  certain  to  produce 
such  a  condition  of  the  atmosphere  as  to  height- 


PURIFICATION    OF    HOSPITALS.  <s  i 

(mi  the  mortality.  It  also  becomes  hnperativta 
upon  those  taking  care  of  such  infectious  pa* 
dents  to  breathe  the  air  as  little  as  they  can-:  live 
out  o\'  the  room  or  tent  as  much  as  possible, 
compatible  with  the  proper  attendance  upon  the 
sick,  and  take  exercise  freely  in  the  open  air. 
Surgeons  placed  under  such  circumstances  must 
take     additional     care     of    themselves.        Personal 

cleanliness  becomes  a   necessity;   the   liberal  use 

of  the  hath,  and  the  frequent  changing  of  their 
clothing,  will  he  found  a  wise  sanitary  precau- 
tion. Their  diet  should  consist  of  simple  and 
easily  digested  food,  with  wine  in  moderation. 
They  should  avoid  all  excesses,  hoth  in  eating 
and  drinking,  as  those  addicted  to  intoxication 
and  gormandizing  are  placed  in  the  same  cate- 
gory with  the   weak  and   poor,  from  which  classes 

the    mortuary    tables    of    epidemics    are    chiefly 

made.  The  surgeon  should  live  out  of  the  hos- 
pital, and  should  not  enter  the  hospital  in  the 
morning  until  the  wards  have  been  well  aired. 
In  taking  exercise  in  the  open  air.  fatigue  must- 
be  avoided.  His  mind  musi  he  tree  from  all 
anxiety  or  personal  fear  of  the  disease.  lie 
should  take  a  full  proportion  of  Rlocp,  and  in 
the  general  care  of  his  person  should  watch 
every  indisposition,  and  correel   derangements  of 


v_'  PI  BtlFICATlON    OF    HOSPITALS. 

the  digestive  syateni  before  they  lead  to  more 
serious  conditions.  Tin-  nuedieal  attendants  upon 
typhus  hospitals,  or  in  such  as  arc  infested  with 
pysemia,  gangrene,  <'t<\.  should  frequently  change 
placet  with  those  in  charge  of  more  healthy  in- 
stitution-: otherwise,  the  permanent  medical  at- 
tendant, inhaling  daily  this  poisoned  atmosphere, 
will  be  sacrificed  to  an  absence  of  a  regular  in- 
terchaage  of  stations  and  duties. 

In    the    best    regulated    hospitals,  each    typhus 
ease   has   two  beds.     Every  twelve   hours   he   is 

changed,   and     the    bedding    upon    which     he    has 

been  Lying  fumigated  and  well  aired.  The  bed 
and    body  linen    of  Bucb    is  also   changed  daily. 

As  typhus  is  known  by  its  infecting  nature  and 
it-  easy  transmission,  the  hospital  wards  cannot 
be  protected    by  too   many  hygienic  regulations. 

When  a  hospital  has  become  infected  with  ty- 
phus, pyaemia  or  hospital  gangrene,  it  is  best  to 

close  it  and  turn  out  all  patients.  It  would  he 
much  safer  lor  the  sick  and  wounded  to  stay  in 
the    streets   or    lie     in     the     field,    than     he   sent    to 

such  an  infected  establishment  Hi*  permit  for 
admission  is  his  death-warrant  :  whilst  combat- 
ing tin-  elements  would  give  him  at  least  a 
chance  of  coming  off  conqueror.  Any  tempo- 
rary,    well-ventilated     structure  —  a     hut     rudely 


FEMALE    NURSES    IN     UOS1MTAI.S. 

made  of  rough  boards— would  be  Irfach  health- 
ier  than  gorgeous  palaces  with  gilded  chambers, 
in  Which  Death  sits  in  state  to  WCfrive  his  vic- 
tims. 

In    general    hospitals,   the    blessings    of   a    wo- 
man's care,  her  ewwatehful    eye  and   soothing 
words,  her  gentleness  and  patience,  have  recently 
been  felt     Florence  Nightingale,  when  she  made 
her    disinterested    offer    to   nurse   the  sick    in   the 
Crimea,   could    have  little    foreseen    the    new  era 
dawning  for    suffering    humanity,  and    the   bene- 
fits which  she  was    bestowing  upon  future  gene- 
rations.     It    is  woman's  peculiar    prerogative,  as 
it    is    her    earthly    mission,    to    give    comtort     to 
thosfl   in  distress  ;   and  when  the  EngKsh  adopted 
the   custom     long    prevalent    in    France,   to    allow 
female  nurses  to   minister  to  the  wants  ni    fefeoee 
suffering    in    military   hospitals,   the   wounded   felt 
that   half  their    solicitude   was   removed.       Xow   a 
Sisters  care  will  bathe  the  sufferer's  aching  head. 
or    offer    him    the    cooling    draught    to    allay  his 
putted  thirst:   will    sympathize   with    his    pains, 
and  --ive  sweet   consolation   to  his  dejected  spirit; 
ami,    by    removing    that    overpowering    weight    of 

Loneliness,  by  which  the  sick  in  a  foreign  laud 
far  from  home  ami  friends  are  oppres>ed.  will 
pave  the  r«.ad  to  speedy  convalescence.     A  cheer- 


•I  I  KM  \l.l      M    R  -I   -     IN      I.         MTA1 

t'ul  look.  :i  kind  word,  r  pleasanl  smile  from  one 
of  these  self-denying  Sisters,  has  Bent  many  a 
Thrill  of  pleasure  through  :i  stricken  soul.  The 
surgeon  sec-,  at  Ins  next  visit,  the  fruil  of  thin 
pleasantly-administered  draught,  whieh,  perhaps, 
In-  attributes  to  his  own   nauseous  drug 

The  experience  of  the  Crimean  hospitals,  recog- 
nizing the  vast  amount  of  good  which  the  female 
nurses  accomplished,  and  the  incalculable  servie* 
which  they  are  capable  of  performing,  when  judi- 
ciously selected  and  properly  organized,  is  a  suffi- 
cient reason  why  they  should  be  attached  to  every 
hospital,  and  especially  in  times  of  war,  when 
their  many  and  peculiar  services  cannot  be  dis- 
hrihnl  with.  To  tin-  surgeon,  a  good,  kind,  re- 
liable nurse  constitutes  more  than  half  the  treat- 
ment of  the  sick.  It  is  with  the  most  serious 
cases  tlwit  their  advantages  in  nursing  are  beat 
displayed.  McLeod,  who  studied  carefully  Wo- 
man's services  iii  the  Crimean  hospitals,  says: 
■•  A  woman's  services  in  a  hospital  are  invaluahle. 
if  they  were  of  ih>  further  use  than  to  attend  to 
the  cooking  and  the  linen  departments;  to  sup* 
l>lv  'extras'  in  the  way  of  little  comforts  to  ihe 
worst  cases;  to  see  thai  the  medicines  and  wine 
Ordered  are  administered  at  the  appointed  peri- 
ods, and  to  prepare  and   provide  suitable  drinks. 


FEMAJM    NlltsKS    IN    HOSPITALS.  85 

As  to  the  employment  of  'ladies,'  I  think  they 
arc  altogether  out  of  place  in  military  hospitals, 
except  as  superintendents.  As  heads  of  depart- 
ments, as  organizers,  as  overlookers.  '  otlmers'  of 
tin'  female  corps,  it*  yon  will,  they  rannot  he 
dispensed  with  ;  bat  for  interior  posts,  strong, 
aetivr,  respectable  paid  nurses,  who  have  under- 
gone a  preliminary  training  in  eivi]  hospitals, 
should  alone  be  employed.  In  camp  hospitals, 
Which,  with  an  army  in  the  field,  are  merely  the 
temporary  resting-places  of  the  sick,  men  should 
alone  he  employed  as  nurses:  but  in  the  more 
fixed  hospitals  in  the  rear,  the  lady  superintend- 
ents and  under«nurses  should,  in  my  opinion, 
always  he  added  to  the  regular  staff.  Their 
attention  should  be  limited  to  the  had  cases, 
and  they  should  have  the  entire  control  of  the 
linen,    medical    eomforts,   and    cooking. 

!  cleaning  should  he  done  hymen.  There 
should  be  a  lady  superintendent  over  each  divis- 
ion of  the  hospital,  responsible  to  the  surgeon  as 

well  as  to  her  own  lady  chief.  Then  there  should 
he  a  store  of  -extras'  under  her  charge,  distribu- 
table on  requisition  from  the  medical  attendant, 
and  which  depot  should  he  tilled  up  to  a  certain 
quantity  weekly,  the  Sister  being  held  accounta- 
ble for  the  contents.      Wine  and  all  extras  should 


v"  m  if  i\  ROftprr  \i  i 

pass  through  her  hands.  She  shook!  be  responsi- 
ble for  the  due  performance,  by  her  female  >ul>- 
ordiuatea,  <>t'  their  duties,  and  have  a  rigfcl  t<> 
interfere  with  the  ward-maater  it'  the  cleaning', 
•4c.,  is  not  properly  attended  to  by  his  male 
corps." 

'/'/-<  dieting  of  patients  wi  a  hospital  is  alwaya 
;i  natter  of  oouaiderable  moment,  and  one  which 
reqoirea  much  attention.  The  Burgeon  haa  die- 
cretionary  powers  to  order  any  extras  which  the 
patients  may  need  and  which  the  iaaoe  of  rations 
not  include.  To  l»c  enabled  to  supply  these 
extra  articles  at  the  time  when  they  arc  wanted, 
and  not  depend  Upon  the  doubts  and  uncertain- 
ties of  the  regular  form  through  which  all  such 
orders  now  pass — n  kind  of  circumlocution  office, 
where,  in  time,  the  articles  may  be  forthcom- 
ing— the  medical  director  should  be  supplied  with 
funds,  for  the  judicious  outlay  of  which  he  be- 
eomea   personally    reaponaible.      From    this   fund 

the  wants  of  the  patients  can  he  supplied  with- 
out   delay. 

Another  mode  of  supporting  tin-  commissariat 
of  a   hospital,   is   by   commuting  the   number  of 

weekly  rations  which  the  inmates  are  entitled 
to  draw.  As  the  sick  cannot  consume  the  full 
ration     allowed     them,    the    difference     not    used, 


TUKT    I\    HO8PITAL8. 


ST 


wbieb  is  considerable,  would,  in  time,  establish 
an  hospital  fund,  which  Would  not  only  be  suf- 
ficient to  meet  all  of  the  necessary  demands  of 
the  sick,  lmt  would  also  supply  them  with  many 
luxuries.  When  the  patient  can  Consume  his 
entire  ration,  lie  should  be  discharged  from  the 
hospital    and    returned    for    dUty.       This    hospital 

fund  is  in  the  keeping  of  the  Burgeon,  who  has 

the  right  to  expend  it  tor  the  benefit  and  eoiu- 
fort  Of  the  patients — the  articles  purchased  not 
being  restricted  to  articles  of  subsistence. 

For  the  very  sick,  the  dietary  orders  being  indi- 
vidual, no  difficulty  exists  in  prescribing  for  them. 
It  is  tor  those  drawing  ordinary  fare,  and  who 
require  to  he  guided  by  some  fixed  rule,  that  diet 
tables  are  found  so  useful  in  diminishing  the 
daily  routine  duties  of  the  surgeon^  This  diet 
li-l  i-  carefully  compiled  by  the  medical  directors 
of  th«'  hospital,  and  contains  those  articles  of  diet 
which  would  be  besl  suited  to  the  many.  As 
this  i.>  a  811H  >/""  UOfl  in  a  hospital,  and  gives 
much  trouble  in  its  preparation,  I  have  here  in- 
troduced, as  a  guide^  a  diet  table,  which  mighl 
he  useful  as  a  basis  in  preparing  one  for  indi- 
vidual hospital  service. 


sa 


MM     IN    HOSPITALS. 


.1  Schenu         !■  '■  Patients  in  tin     \IUit<        II 


II   l.l     DIKT. 


II   M    I      H1KT. 


1   »\\     I'll    T. 


I  !!•    Breaa 1   II..  Brea.l >.  II,. 

Beef  or  M.iii  ,u. . .  or  Matto |    lb.  Tea 

Potatoes,  or  ]    ....  1  lb.  Potatoes,  or  "\ 1   lb. 'Snjrar 

Beans,  or. I  ■■  .  B  an?,  or I  ■  ••    Milk  for  tea  f  •  .L^i-. 

!:•  •   i    I to     Corn  Mi  :.l 1   H>. 

•n|i. .  I  oz.  \     pt'es  for  soup . .  4   oz.  Milk I   ok 

Bnfi l  ,,/..  m'i l  oj 

o  .  Tea 1  >,/. 

i 1  oz.  Sujfar l'  ,,/ 

2  "/..  Milk  for  tea I  os 

r  ten i  oz.  MolasPe* |   ,,• 

I  ua.lCoro    Meal I   I  i> 

Cora   Meal 1  lb    Sou] '       

.Snip I     pt i 

-sucb  quantities,  in  lieu  of  beef  and  mutton, 
as  !h'.'  in  'lh-.il  officer  may  prescribe. 

\\  i:  ■  ,  Whiskey j  Porter  or  \\<-.  :>'  the  surgeon's  discretion. 


Two  drachma  of  tea  or  tour  of  coffee,  with  one 
ounce  i'f  sugar  and  one-eighth  pint  of  milk,  to 
lit-  allowed  to  each  patient  for  one  pint  of  tea  or 
coffee  morning  and  evening. 

The  beef  or  mutton  for  full  or  half  diet  is  to 
lie  made  into  soup,  with  vegetables,  ami  one  pint 
of  the  soup  given  to  each  patient,  with  his  pro- 
portion of  the  boiled  meat.  The  vegetables,  as 
lire,  potatoes  or  beans,  arc  frequently  changed  to 
give  variety  to  the  meal. 


DIET    IN    HOSPITALS. 


89 


The  diel  Mould  be  distributed  in  the  following 

order : 


I    Bread *  lb, 

BHBAKFA.8T.       Tea  or  ooffee..l  pt. 

(    Iliuniiiv  &  molasses. 


1>i\  \  in. 


Supper, 


i  Beef  or  mutfon.j  lb. 

1  Soup 1  pt, 

1  Bread \  lb. 

(  Bi : « 1 1 .-- .  potat's  or  ruse 

I  Bread ^  lb 

-  Tea  or  coffee  .  •  I  pt. 


Bread a  lb. 

Tea 1  pt, 

II  mnir,  v  &  mo 

Beef  or  mutton.j  lb. 

Snap 1   ).t. 

Bread 1  lb. 

Bcans,p»tal  'a  or  riee 


Bread. 

Tea . . . 
Q-ruel . 


Gruel 
Milk., 


•  1  lb. 
.1  pt. 
•ipt. 


.lpt. 

.1  pt. 


Bread }  lb.  Br  a  ! . 

fea 1  pt.  Tea. .  ■ 

Q-ruel. 


•  j  lb. 
.lpt. 
.A  pt. 


The  attending  surgeon  adds  what  he  wishes  to 
the  above  diet,  to  suit  any  individual  case  in  the 
hospital. 

For  regimental  or  post  hospitals,  where  diffi- 
culty exists  in  obtainiug  proper  ihgrediehts  for 
furnishing  a  good  soup  to  the  sick-,  the  medical 
department  issues  "Jones'  soup  or  meat  cakes," 
which  contain  all  the  necessary  elements  for  its 
preparation.  These  cakes,  which  are  composed 
of  meat  and  vegetables,  when  boiled  lor  ten  or 
fifteen  minutes,  wifb  ;i  sufficient  quantity  of 
water,  will  make  a  nutritious  diet  for  convales- 
cents. 


CHAPT  E  l;     MI. 

.1/      al  ServUn  of  the  Arm;/—  Tin  means  of  Trans- 

porting   //><■    si,-/,-   and  wounded — II"  ml   Litters  — 
Horse   Utters — Ambulance    Waggons,  </<■. 

Tin-  transportation  of  the  sick  and  wounded  of 
an  army  is  always  a  matter  of  difficulty,  and  is  not 
uncommonly  the  indirect  cause  of  an  increased 
mortality.  The  injury  inflicted  upon  a  wounded 
man  by  a  transportation  <>f  even  a  lew  hours  oyer 
bad  roads,  and  in  unsuitable  vehicles,  is  incalcu- 
lable. Wounds  which  laid  been  doing  well  prior 
(o  the  move,  take;  on  at  once  an  unhealthy  appear- 
ance :  some  slough  :  erysipelas  or  mortification 
shows  itself  in  others,  whilst  all  feel  more  or  less 
its  malignant,  injurious  influence,  even  with  the 
besl  transports,  and  under  the  most  favorable  cir- 
cumstances. 'Idie  jolting  of  a  broken  limb  for 
three  or  tour  hours  over  a  rough  road,  is  inde- 
scribable torture.  The  prostration  and  exhaust- 
ion depicted  upon  the  laces  of  the  wounded  after 

such  a  transfer,  explains  ;tt  ^wrr  the  problem  why 
such  numbers  die  during  their  transportation,  and 


TRANSPORTATION    OF    SICK    AND    WOTTNPKD.  91 

makes  us  wonder  bow  so  many  escape  with  life. 
after  undergoing  such  unutterable  hardships. 

The  transportation  of  the  sick  should  also  be  a 
source  of  anxious  solicitude  on  the  part  of  a  quar- 
termaster whose  humanity  has  not  been  berefl  of 
every  spark  of  sympathy.  It  is  said  that,  in  the 
service,  the  privation  and  the  usual  demoralizing 
agents,  always  at  work  and  so  widely  diffused, 
destroy  all  the  finer  feelings  of  a  man,  making 
him  not  only  careless  of  self,  but  callous  to  the 
wants  of  others.  It  is  only  similarity  of  suffering 
that  can  produce  sympathy  in  feeling.  Could 
ihose  in  the  Quartermaster  department  undergo 
ihe  same  treatment  which  falls  to  the  lot  of  the 
sick  during  transportation,  there  would  be  a  few 
more  comforts  extended  to  those  who  are  risking 
their   lives   for   their   country. 

Who  can  describe  the  agony  of  that  fearful 
ride,  which  so  many  thousand  sick  were  forced 
to  take,  from  Manassas  to  the  provincial  and 
metropolitan  hospitals,  where  a  six  hours  ride 
by  railroad  was  often  extended  to  two  days,  the 
sick  lying  in  box  and  cattle  ears,  without  food. 
and  often  without  water.  Should  it  rain,  which 
it  diil  nearly  every  day,  these  poor,  brave  fel- 
low-, who  had  left  every  comfort,  if  not  luxury, 
at  their  country-  call,  soaked   to  the  skin,  with- 


'~     * 


u 


TRANSPORTATION    OF    SH'K    AM)    WOUNDED. 

<>ui  ;i  change  of  clothing,  would  remain  in  this 
plight  until  they  arrived  at  a  hospital,  whieh,  in 
iurn.  wan  often  ban  or  twelve  hours  after  their 
arrival  in  the  city.  Human  nature  could  not  en- 
dure such   trial.-,   ami   many    succumbed    in    tran-it 

i>r  reached  the  hospital  to  die  a  few  hours  after 
admission.  If  the  proper  care  had  been  taken, 
ami  car.-  had  been  judiciously  arranged  i'<>r  the 
comfortable  and  rapid  transportation  of  the  sick, 
many  a  valuable  life  would  have  been  saved* 
The  following  arc  the  usual  modes  of  transport- 
ing those  wounded  during  a   battle: 

Lirb&s.  —  The    common    and    best    means    o€ 

moving  wounded  men.  for  short  distance-,  i- 
ii)ioii  Litters,  which  may  be  prepared  in  advance, 
or  be  an  impromptu  manufacture.  In  case  of 
necessity,  a  Litter  can  al  once  be  made  from  the 
blanket  of  a  soldier.  This  is  doubled  upon  itself, 
a  slit  being  made  through  the  end  corners  suffi- 
ciently Large  to  admit  the  barrel  of  a  musket: 
one  musket  is  passed  through  the  fold  of  the 
blanket,  another  through  the  slits  in  the  ends, 
ami  a  litter  i>  ready  lor  use.  Soldiers  blankets 
arc  at  times  prepared  lor  this  service,  by  having 

Strong  loop-  sewed  to  the  corners,  so  that  when 
the   blanket    is  doubled   the   lour  loops  will   come 


TRANSPORTATION    OF    SICK    AND    WOUNDED.  9$ 

on  one  straight  side  :  one  musket  is  passed 
through  the  four  loops,  the  second  through  the 
folded  blanket.  Whert  comrades  from  the  ranks 
are  expected  to  carry  off  llio  wounded,  this  is  the 
only  litter  which  is  of  service,  as  any  two  sol- 
diers are  prepared  to  act  as  transports,  without 
hampering  themselves  during  the  tight  with  extra 
baggage.  Such  a  litter  is.  however,  very  defect- 
ive, as  the  weight  of  the  patient  sags  the  yielding 
blanket  until  it  nearly  reaches  the  ground,  whilst 
the  muskets  are  pressed  in  upon  the  haunches 
or  the  bearers,  which  renders  it  impossible  for 
them   to   proceed   with   ease  or  celerity. 

A  more  useful  and  equally  simple  litter  or 
stretcher  is  made  of  strong  sacking  or  canvas, 
six  feet  i«»ur  indies  long  and  two  feet  wide.  A 
broad  hem  is  taken  up  on  either  side,  through 
which  readily  pusses  a  stout  pole  eight  feet 
hmg.  <>n  either  side  of  the  litter  is  an  iron  or 
-tec]  rod  two  (ret  ]oug.  with  rings  at  the  ends, 
which    slip   over   the   cuds   of  the    poles   and    form 

the  stretcher,  to  keep  the  poles  separate,  and 
prevent  any  sagging  of  the  litter.  A  shoulder 
strap,  with  a  loop  ou  either  end  to  receive  the 
poles,  completes  an  apparatus  which  is  capable 
of  carrying  oil"  a  wounded  man  with  all  the 
•mfort     with    which    his    situation    admits.      A 


94  ^NSPORTATION    f»F    SICK    ANP    WOrVT>KT>. 

pike  head  attached   to  the  pol  -   it   a   P 

midable  wea] of  defence.     Each  of  those  who 

I  to  transport  (he  wounded,  is  armed 
with  such  a  pike,   and  1ms  one  iron   I  o¥ 

Btretcher  and  canvas  bottom  Btrapped  upon  his 
knapsack.  Any  tw<>  of  tl i«i 1 1  meeting  tos^ethef 
will  be  enabled  in  :i  few  minutes  to  equip  an 
efficient  litter.  When  placed  in  the  litter,  the 
soldier's  knapsack  is  placed  under  his  1i«:h1  as 
a  pillow,  and  Lis  musket  lies  alongside  of  him, 
or  may  be  hung  from  the  side  of  the  litter  by 
loops  placed  there  for  thai  purp< 

A  framed  litter  is  one  of  very  questionable 
utility,  as  it  is  a  very  bulky  article,  and  6ne 
easily  broken,  so  thai  usually,  after  a  long  trans- 
portation, very  few  of  them  are  tit   for  BervTce. 

The  litters  1 1 - » • « 1  in  the  Confederate  service 
are  composed  of  canvas,  twenty-four  indies  wide. 
securely  tacked  to  two  horizontal  bars  ei-ht  feet 
long;  the  stretchers  which  slip  over  the  han- 
dles, and  to  which  the  canvas  is  temporarily 
ired  by  strap-,  being  a  square  bar  of  wood, 
with  a  loop  of  band  iron  over  the  r]\i}<.  forming 
the  eyes  through  which  pass  the  handles.     These 

:iiv    convenient,    as    they    fold    in    ;i    small    compass 

for  transportation.  A.s  the  stretching  apparatus^ 
which  is  loose,    is   sometimes   losl  or  misplaced; 


TRANSPORTATION    OF    SICK    AND    WOUNDED.  95 

which  venders  the  litter  useless,  it  may  be  se- 
cured to  the  side  bars  by  hinges.  Short  fold- 
ing legs,  working  upon  an  iron  pivot,  and  kept 
in  place  by  a  stop-block  or  an  iron  hook,  per- 
fect the  apparatus.  In  the  Confederate  service, 
ten  of  these  arc  issued  to  each  regiment  in  the 
field. 

Williamson,  in  his  Notes  on  the  "Wounded 
from  the  Mutiny  in  India,  published  in  1850, 
lias,  in  the  appendix,  a  plate  and  description  of 
a  fooley — a  kind  of  litter  used  for  the  convey- 
ance of  the  sick  and  wounded  in  India.  In  the 
field  service  it  forms  the  patient's  bed  as  well 
as  means  of  conveyance,  from  the  time  of  bis 
being  wounded  until  be  is  either  cured  or  dies. 
It  consists  of  a  frame-WOrk,  resembling  a  bed- 
stead in  miniature,  six  and  a  half  by  two  feet, 
with  light  posts,  which  run  below  the  bed  six 
inches.  This  is  slung  by  two  ropes  placed  on 
either  side  from  the  head  and  foot,  and  running 
up  triangularly;  the  pule  upon  which  the  litter 
i-  supported  passing  through  the  apex  of  these 
two  triangle.-.  A  tarpaulin  cover,  with  side 
curtain-,  excludes  tic  sunlight  and  gives  privacy 
to  the  wounded.  When  the  bearers  arrive  at 
the  encampment,  they  run  the  dooley  into  the 
hospital    tent,    take    out    the     pole    with    the    tar- 


paulih  covering  and  curtains,  with  which  they 
make  their  tent,  leaving  the  patient  comforta- 
bly in  his  bed.  These  were  found  t<»  answer 
admirably  in  the  Crimea,  where  they  were  used 
to  a  limited  extent*  This  is  the  raosl  comforta- 
ble conveyau#6  for  a  Bick  or  wounded  person, 
nii<l  it >  introduction  generally  into  the  English 
service  has  been  Btrongly  recommended. 

Horse  Litters. — Next  to  hand  litters  for  the 
transportation  of  Wounded  men  are  horse  litters, 
made  three  feel  wide,  with  poles  sixteen  feet 
long,  folding  in  the  middle  for  convenience  6t 
transportation.  Elorsea  <>r  mules  take  the  place 
of  men  —  the  poles  acting  as  shafts,  and  su|i- 
ported  by  back-straps  or  by  a  saddle  with  tugs, 
as  in  ordinary  harness.  Each  horse  litter  carries 
two  persons.  When  the  mules  are  led  by  men 
well  trained  for  this  duty,  transportation  by  tins 
means  is  well  suited  to  the  comfort  of  the 
wounded;  bu1  if  the  muleteers  are  raw  hands. 
who,  holding  the  mule  by  the  head,  attempt 
to  lead  it.  instead  of  allowing  it  to  pick  its 
own  way.  the  joltings  and  sudden  jars  make 
this   litter  anything   but  a   bed  of  down. 

The  French  use  what  is  called  a  cacolet,  a 
kind  of  arm-chair,  which  is  suspended  on  either 


AMBULANCE    WAGONS.  97 

side  of  a  pack-saddle  upon  a  mule.  The  me- 
chanism of  this  chair  is  so  arranged,  that,  it 
can  be  unfolded,  so  as  to  he  converted  into  a 
bed  or  a  litter.  It  offers  either  a  comfortable 
seat  for  the  trivially  wounded,  or  a  bed  for  the 
more  serious;  and  each  mule  can  thus  carry 
two  men  comfortably,  from  the  held  to  the  in- 
firmary. In  hilly  countries,  over  had,  rough 
roads,  this  is  found  a  much  better  conveyance 
than  vehicles. 

The  two  and  four  wheel  carriage  <>r  ambulance 
wago7is,  which  have  been  adopted  in  every 
civilized  army,  are  considered  indispensable  for 
held  service,  and  for  the  transportation  of  the 
wounded.  The  two-wheeled  vehicle  is  the  most 
comfortable.  Both  two  and  four  are  so  ar- 
ranged as  to  allow  of  the  wounded  being  car- 
ried lying,  reclining,  or  sitting.  The  omnibus 
i>  the  most  expeditious  means  of  removing 
those  slightly  wounded,  who  are  not  able  to 
walk  from  the  field.  Where  1  lie  roads  are 
good,  in  an  open  country,  this  vehicle  should 
not  he  overlooked.  The  two-wheeled  spring 
ambulance  wagon  is  the  most  comfortable  for 
the  wounded,  hut  not  the  most  useful  for  tin- 
In    the    Confederate    &  the    four-wheel 


t 
A.MBI  I.AM'K    WAOON8. 

Bprillg     WagOU      M     the     one     ill     general      Use.        it 

consists  of  a  square  body,  three  and  a  hall'  feel 
wide  and  seven  and  a  hall'  feet  long,  placed 
upon  three  springe.  Two  stuffed  seats  run  the 
entire  length  < •!'  i  1m-  wagon;  and  the  drop  from 
this,  which  is  attached  to  the  seal  by  hinges, 
and  is  equally  cushioned,  can  lie  elevated  hori- 
zontally, and  supported  by  feet,  which,  with  the 
seat*  will  form  a  continuous  bed  over  the  entire 
wagon.  Such  wagons  will  transport  two  men 
lying,  or  from  ten  to  twelve  Bitting  —  the  in- 
mates being  protected  from  the  sun  and  rain 
hv  a  doth  cover  ami  side  curtains,  supported 
upon  a  frame.  Two  five-gallon  kegs,  secured 
under  the  bottom  of  the  wagon,  will  carry 
water    for    the    sick    and    wounded. 

The  Coolidge*  two-wheel  ambulance  wagon, 
which  is  in  use  in  the  Federal  army,  is  a  wvy 
ingenious  hut  complicated  arrangment,  which  is 
liable  to  he  broken  by  the  ordinary  abuse  of  the 
service.  In  these,  instead  of  seat<.  there  are 
two   frames,   which   can   he   used  as  litters.      These 

run  upou  rollers  on  the  bottom  of  the  wagon. 
The  frames  have  folding  legs  and  sliding  handles. 
which  occupy  no  available  room.  Upon  the  top 
of    the    litter    i-    a    frame,   divided   into   three  por- 


AMBULANCE    WAGONS.  M 

tions,  folding  in  such  a  way  that  the  head  of 
a  wounded  man  can  he  elevated  nearly  to  a  sit- 
t i  1 1 iz:  posture,  or  the  leg  equally  elevated,  should 
the  peculiarity  of  the  wound  require  it.  A  par- 
tition through  the  body  of  the  wagon  sepa- 
ratee the  two  patients  which  the  wagon  carries. 
Under  the  driver's  scat  is  a  box.  which  can  be 
used  as  a  medicine-chest.  This  vehicle  is  in- 
tended for  one  horse  in  shafts,  or  two  in  tandem. 
The  Confederate  service,  based  upon  the  army 
regulations  of  the  United  States,  allows  for 
every  command  of  less  than  three  companies 
one  two-wheeled  transport  cart  for  hospital  sup- 
plies, and  to  each  company  one  two-wheeled 
ambulance  carriage.  For  commands  of  more 
than  three  or  less  than  five  companies,  two  two- 
wheeled  transport  carts,  and  to  each  company 
one  two-wheeled  ambulance  carriage.  For  a 
battalion  of  five  companies,  one  four-wheeled 
ambulance  carriage,  five  two-wheeled  and  two 
two-wheeled  transport  carts:  and  for  each  addi- 
tional company,  less  than  ten,  one  two-wheeled 
transport  cart.  For  a  regiment,  two  four-wheeled 
ambulance  wagons,  ten  two-wheeled  ambulance 
wagons,  and  tour  two-wheeled  transport  carts. 
Where  there  ire  manj    sick   to   be  moved   from 


TOO  AMBULANCE    WAGONS. 

camp  to  a  general  hospital,  Bhould  the  transpor* 
tation  in  ambulance  wagons  be  deficient,  ad- 
vantage is  taken  of  the  return  of  empty  com  mis- « 
sarv  wagons  t«>  the  rear  to  send  off  the  sick,  and 
vehicles  « > t "  every  description  may  l>e  impressed 
for  this  special  service. 


CTT  A  P  T  K  R     TV. 

Medical  and  Surgical  Staff  of  Armies — 7%<  Medical 
organization  hi  the  Confederate  service;  English 
service;  French  service;  Prussian  servici — Sani- 
tary Corps,  "/•  litter  carriers  for  transporting  ile 
wounded  from  H<<  ti</<? — ThMes  <>/  the  Hospital 
Surgeon — Duties  of  tfo  "Regimental  Surgeons  and 
Assistants  in  camp  "ml  on  the  batth  field — Pre- 
parations needed  <>n  the  eve  of  a  batth  —  Positions 
occupied  by  tin   Medical  Staff  during  the  figftt. 

Medical  Service  of  the  Army. — The  medical 
staff  of  an  army  i>  selected  with  care  by  an  ex- 
amining board,  whose  rigid  inquiries  into  the 
literary  and  professional  attainments,  as  well  as 
into  the  moral  and  physical  condition  <>t'  the  ap- 
plicant, keeps  the  start'  purged  of  inferior  men. 
ami  forma  a  body  of  scientific  investigators 
whose  efficiency  will  compare  favorably  with  the 
profession   of  any  country. 

During  war.  the  Medical  department  increases 
puri  passu  with    the  army.      These  appointments 


102  M  K I  •  I « •  \  I .    STAMP. 

ghoald  be  made  with  ;i  lull  knowledge  of  the 
weighty  responsibilities  attached  t<»  the  medical 
-t:itl'.  without  whose  constant  solicitude  for  the 
health  and  well-being  of  tin-  troops  committed 
to  their  care,  the  effective  strength  of  an  army 
will  he  materially  reduced.  With  a  view  to  en- 
sure, at  nil  times,  the  most  active  and  efficient 
treatment  for  the  -irk  in  the  army,  ami  particu- 
larly during  active  service,  it  is  not  only  essen- 
tial that  the  medical  officers  should  he  men  of 
ability  and  of  high  professional  qualifications, 
hut  that  they  .-houhl  possess  physical  energy 
adequate  to  the  more  arduous  duties. 

It  is  ;i  common  impression  that  Burgeons  alone 
me  wanted  in  the  army,  under  the  erroneous  be- 
lief that  the  only  risks  to  which  troops  arc  ex- 
posed are  the  bullets  of  the  enemy.  A-  we 
have  elsewhere  shown  that  tor  one  killed  by 
tin-  enemy  sixteen  die  of  disease  contracted  in 
camp,  this  will  he  sufficient  proof  thai  the  phy- 
sician iii » i  —  1  he  even  more  important  than  the 
surgeon.  Long  before  the  first  shot  ia  fired 
there  are  disi  •  contend  against.      Whether 

in  camp  or  on  the  march,  diseases  are  constant- 
ly developing  themselves.  Surgery  has  its  peri- 
ods, and  although  hospitals  niav  he  tilled  imme- 
diately   alter    a    fight,    beds    are    soon   vacated    to 


MK1UCAL    STAFF.  Ltift 

the  ever  coming  siek.  Some  of  the  wounded 
die,  a  large  proportion  rapidly  get  well  and  are 
discharged,  and  the  protracted  cases  ace  sent 
home  to  recruit;  but  these  leave  no  vacancies, 
as  their  places  are  immediately  tilled  by  the  sick. 
The  advantages  of  having  an  experienced  sur- 
gica]  Btaff  in  the  field,  and  the  influence  which 
it  can  exert  on  tlic  vicissitudes  of  war,  must  be 
acknowledged    by    every    thinking    man.      Yet, 

medical  advice  is  seldom  asked  or  listened  to 
by  those  in  command,  so  long  as  Buffering  and 
deatli  are  not  cruelly  felt.  The  proper  under- 
standing between  the  surgical  and  military  staff' 
of  an  army,  with  concert  of  action,  will  save 
many  a  soldier  who  would  otherwise  Lose  or 
com  promise  his  life,  so  valuable  to  the  country 
in  time  of  need. 

In  the  Confederate  service,  but  two  grades  in 
the  medical  staff  arc  recognized — surgeons  and 
assistant  sururvons.  with  the  respective  assimila- 
tive rank  of  major  and  captain.  The  head  "f 
the    Medical    depart  incut     is    presided    over    hv    a 

Surgeon-General,  with  the  rank  of  Lieutenant- 
Colonel,  which   i>  the  higheal   grade   in    the    mt- 

viee.  and  which  position  is  n  promotion  by  sen- 
iority <>f  commission.  There  are  two  other 
meritorious    positions    of   medical    directors    and 


medical  purveyors  of  the  array,  which  are  ap- 
pointments from  tlic  Surgeon-General,  and  are 
considered    high    offices,    although    without     in- 

i  'I  rank. 
In    the    Confederate   service,  each  regiment  of 

thousand  men  has  one  surireon  and  '>n<-  as- 
Bistanl  surgeon.  Where  Beveral  regiments  are 
united  into  brigades  and  divisions,  the  Surgeon- 

ral  usually  assigns  the  oldest  surgeons  in  the 
service,  acting  in  Buch  a  division  <>f  the  army, 
to  th  of   Medical    Director  t<>  superintend 

the  medical  affairs  for  Buch  a  division,  unless 
In-  make-  a  special  appointment,  irrespective  of 
l<>r;il  medical  staff.     In  times  of  peace,  these  two 

tental  officers  are  found  scarcely  sufficient 
t<.  attend  t<>  tin-  sick;  whilst  in  times  <>f  epi- 
demics  or  war,  they  are  Incompetent  to  offer 
that  assistance  which  the  sick  and  wounded  re- 
quire. Many  a  life  lias  been  sacrificed  bo  pro- 
crastination. Upon  the  first  and  immediate  atten- 
tion to  the  wounded  <>n  the  battle  iiel<l  depends 
in  a  great  measure  the  success  of  treatment;  Mid 
in  any  encounter  which  deserves  the  name  <>f  a 
battle,  the  wounded  must  necessarily  be  nee 
<•<!   by  thi-   deficient    medical   stall". 

Our  experience  in  the  Mexican  war  proved  the 
inefficiency   of  <>ur  sparse  medical    corps*      Kuro- 


IN<;i.ls li    SURGICAL    STAFF.  1"~> 

pean  experience  confirms  the  observation,  that 
two  medical  men  are  no<  sufficient  to  takse  etwe 
of  the  health  of  a  regiment.  This  was  the  sub- 
ject of  general  comment  in  the  Crimea,  where 
the  medical  staff  were  unanimous  in  the  de- 
mand for  additional  medical  assistance.  In  active 
service,  every  regiment  should  have  at  least  one 
surgeon  and  two  assistant  surgeons,  these  differ- 
ing only  in  rank,  their  duties  being  similar. 
Besides  the  regular  regimental  sure-cms.  there 
is  in  the  Confederate  service  a  medical  corps  to 
take  charge  of  military  hospitals,  whilst  regi- 
mental  officers    accompany  their  commands. 

In  the  English  service,  the  medical  department 
is  composed  of  regimental  sure-cons,  with  their 
assistants,  staff  sure-eons  of  the  first  and  second 
class,  and  medical  inspectors.  The  staff  sur- 
geons of  the  firsl  class  rank  the  regimental  sur- 
geons, and.  with  their  assistants,  either  take 
charge  of  military  hospitals  or  a<  I  as  medical 
supervisors  lor  a  brigade,  composed  of  three  or 
nore    regiments.       The    assistant    stall*   Burgeon 

holds  the  same  rank  as  the  regimental  SUl'- 
geon.  When  many  brigades  are  collected  into 
a  division,  a  staff  surgeon  of  lone-  service  is  ap- 
pointed to  direct  the  medical  and  surgical  af- 
fairs   of   the  division  :    and   when    a    large    force, 


10<»  1KK.MII     AND    I'KTNSIAN     SlUiiK'AI.    STAFF. 

consisting  of  several  divisions,  with  their  respec- 
tive generals  and  physicians,  i-  brought  into  the 
l'nld  for  actual  service,  and  placed  under  a  gene- 
r;il-in-i]iiet'.  ;i  medical  staff  officer,  bearing  the 
title  of  Inspector-General,  is  appointed  t«>  super- 
intend and  concentrate  nil  the  niovementi  «'t 
the  medical  department  of  tie-  army.  The 
medical  department  take-  the  military,  therefore, 
a-   its   model. 

In  the  French  army,  a  somewhat  similar  or- 
ganization i-  found.  Besides  surgeons  and  as- 
si>t;iut  surgeons  attached  t«>  regiments,  the  mili- 
tary hospital  -lath  which  is  a  rery  numerous 
« > i j * -.  consists  <>f  medical  inspectors  or  head  sur- 
geons «>!'  infirmaries,  stall'  Burgeons  of  the  first 
•  •las-,  with  senior  and  junior  assistants — the  num- 
ber detailed  for  special  hospital  duty  depending 
npon  the  size  of  the  institution  ami  the  num- 
ber  of  it-    inmate.-. 

The  mosl  thorough  medical  organization  in 
Europe  belongs  to  the  Prussian  service,  ami  is 
composed   as   follow 

Kaeh  battalion  of  one  thousand  men  has  a  sur- 
geon and  assistaiil  surgeon,  who  are  thoroughly 
instructed  in  the  duties  which  they  are  expected 
to  perform.  Besides  these,  there  is  to  every  <<<ri>s 
d'armSt   of  thirty  thousand  men.  a  -tali'  of  forty 


LITTER    CARRIERS.  1(17 

surgeons,  who,  in  time  of  war,  take  eharge  of 
the  genera]  military  hospitals  opened  for  the  re- 
ception of  the  sick  and  wounded.  This  division 
li;is  also  attached  to  its  medical  department  three 
infirmary  stalls  for  light  field  service,  composed 
of  eleven  surgeons  each.  These  act  as  a  reserve 
on  tlio  battle  field,  opening  field  infirmaries  which 
follow  the  troops,  and  give  the  first  aid  and  dress- 
ing in  the  wounded.  This  gives  a  proportion 
of  nine  surgeons  to  every  two  thousand  men  ; 
and,  notwithstanding  this  large  number,  there 
are  periods  when  even  a  larger  number  of  sur- 
geons would  not  he  sufficiently  numerous  to  give 
proper  and   immediate  assistance  to  the  wounded. 

In  most  European  armies  the  dispensing  of 
medicines  is  performed  by  apothecaries,  who  com- 
plete the  medical  organization.  In  the  English 
and  American  service,  the  assistant  surgeon  or 
hospital    steward   acts  as   apothecary. 

In  recent  European  campaigns,  a  very  impor- 
tant addition  has  been  made  to  the  surgical  ser- 
vice It  is  the  semtiary  <-<>r/>s,  or  carriers  of  the 
wounded.  Heretofore,  when  men  were  shot  down 
from  the  ranks,  they  were  borne  t<>  the  back  by 
their  comrades  in  alius,  who  transported  them  to 
the  tield  infirmaries,  where  the  Burgeons  attended 
to  iheir  wounds.     Although  a  most  praiseworthy 


L<   -  LITTER    CARRIERS. 

act  of  devotion  to  a  fallen  friend,  it  was  often 
called  for  when  help  could  least  be  Bpared,  as 
tlir  taking  away  <>i'  so  many  fighting-men  from 
the  ranks  enfeebles  the  strength  of  the  command, 
ami  diverts  the  attention  of  the  soldiers,  if  its 
demoralizing  effeel  docs  not  break  u]>  the  corps. 
It  is  also  well  known,  that  if  any  from  the  ranks 
are  drawn  from  the  fight  to  carry  off  the  wounded, 
they  never  return  until  the  fight  is  over,  and  thus 
three  are  lost  to  the  company  instead  of  the  one 
wounded.  Besides,  with  the  very  best  intentions. 
these  comrades  are  not   instructed  how  to  carry 

the  wounded  so  that  thev  should  suffer  least  det- 
riment, and  the  final  result  cannot  he  hut  inju- 
rious to  the  wounded.  The  sanitary  corps,  which 
now  forms  a  very  essential  part  of  continental 
armies,  and  has  been  Strongly  recommended  to 
the  English  service  by  the  surgical  staff  of  the 
army,  is  a  regularly  organized  body,  who  are 
taught  how  to  carry  wounded  men.  These  prac- 
ticed hands  are  under  military  discipline,  with 
officers  whose  duty  it  is  i<>  s,.,.  that  the  wounded 
are  promptly  and  carefully  removed  from  the 
places  where  they  fall  to  tin-  infirmaries. 

There  are  surgeons  connected  with  the  salu- 
tary corps  to  attend  to  the  judicious  transpor- 
tation.     They   only    offer    temporary   assistance. 


LITTER.    CARRIERS.  109 

Should  there  be  fearful  hemorrhage,  they  may 
apply  a  tourniquet,  or  show  tlie  assistants  how 
to  Compress,  effectually,  the  bleeding  vessel:  if  a 
chest  wound,  they  may  ;i!  once  open  a  vein  to 
prevent  the  soldier  dying  in  transit.  They  ar- 
range broken  Limbs  so  as  to  he  conveyed  with 
most  comfort,  and  give  a  dose  of  morphine  when 
ranch  suffering  is  felt,  hut  beyond  this  tempo- 
rary assistance  they  never  go.  This  sanitary 
corps,  with  litters,  ambulance  wagons,  pack- 
horses,  ami  all  other  facilities  for  transporting 
wounded  men,  should  he  in  the  advance,  imme- 
diately behind  the  troops,  when  the  battle  is 
going  on.  Their  post  is  one  of  risk  as  well  as 
of  responsibility;  for,  not  unfrequently,  they  lose 
their  lives  in  accomplishing  their  benevolent  tasks. 
Both  humanity,  civilization  and  economy  dictate 
that  a  similar  corps  should  he  appended  to  every 
army  in  the  held.  When  not  wanted  on  the  hat- 
tie  field,  experience  makes  them  careful  nurses 
for  the  sick  and  wounded. 

The  French  organization,*  which  may  serve  as 
a  model  for  the  formation  of  a  hospital  corps, 
is  as  follows:  One  captain,  one  subaltern,  one  ser- 
geant-major, one  pay  sergeant,  five  sergeants,  or 


*  Article  Ambulance  Costello's  Cyclopedia  of  Practical  Snrgery. 


Hi  4    i 

upper  ward-masters  when  in  hospital,  ten  corpo- 
rals or  tractor  ward-masters,  two  buglers  (indis- 
pensable for  Bounding  halts  and  advance  in  the 
transport  <>f  tin*  wounded  i.  ninctv->i\  | » i  i \  ;i! . 
orderlies,  one  tailor,  one  shoemaker,  one  cutler  (a 
Tii* ► — i  lawful  artisan  t<>  keep  surgical  instruments 
in  repair),  < >n« ■  carpenter,  four  cooks.  \Vheu  earn* 
ployed  in  hospital,  these  are  distributed  in  tin- 
proportion  of  one  ward-master  for  every  hundred 
patient-,  ami  one  orderly  for  every  twelve.  The 
wagons  and  cars  will  alse  be  trader  the  command 
of  their  proper  officers;  noncommissioned  officers, 
with  wheelwright,  farriers,  saddlers,  etc.,  arc  also 
to  be  attached  to  the  corps.  When  on  a  march, 
should  there  be  ■  deficiency  of  transport  wagons, 
the  ambulance  wagons  carry  the  hospital  stores^ 
also  the  packs  a€  weak  men  not  requiring  trans- 
portation; they  also  pick  np  such  men  as  arc  not 
able  to  proceed  with  their  companies,  or  those 
uh<>  are  compelled  bo  fall  out  of  the  ranks  from 
indisposition.  When  troops  on  ■  march  arrive 
at    i    place   where   good   water  can   be  obtained, 

the    hospital    corps    should    till    their    canteens    for 

the  use  of  the  sick.  When  the  troops  arc  bivou- 
acked, the  bospttaJ  corps  should  be  employed 
in  throwing  up  huts,  or  in  establishing  tempo- 
rary  hospitals  in  an\   adjoining  buildings,  and  in 


PRT'SSIAX     MKIUCAL    OROANI/ATION.  Ill 

preparing  some  light  food  for  the  sick  -which 
they  have  brought  in. 

The  following  is  the  course  pursued  />//  t/<<  Hussion 
medfcal  corps  of  <>  division  of  thirty  thousand  nun 
when  going  into  battle:  The  reserve  corps  of  forty 
surgeons  establish  a  general  hospital  at  sonic  sale 
and  convenient  point,  four  or  five  miles  from  the 
battle  field.  Here  all  the  appliances  are 'concen- 
trated for  giving  proper  attention  to  the  injured, 
and  most  of  the  serious  and  tedious  operations 
are  to  be  performed,  under  judicious  consultation. 
As  this  is  the  resting-place  from  the  field,  accom- 
modations must  he  ample:  every  facility  for 
t  resting  successfully  the  seriously  wounded  must, 
therefore,  he  found,  and  all  hospital  stores  should 
be  concentrated   at   this  hospital. 

Directly  behind  the  line  of  battle,  and  mov- 
able with  it,  are  placed  the  light  field  infirm- 
aries, with  their  special  staff's.  They  are  the 
way  stations  for  medical  service,  as  all  the 
wounded  pass  through  these  on  their  way  to  the 
general  hospital.  At  these  field  infirmaries,  the 
wounded  receive  the  first  thorough  examination. 
and  many  operations  deemed  imperative  are  here 
performed.  All  wounds  are  here  cleansed,  for- 
eign bodies  Oi  every  kind  extracted,  hemorrhage 
controlled,   and   the   first    proper  dressing  applied. 


1  U  HUM.    ORGANIZATION. 

ne  wounded  are  brought  bo  this  point  as 
they  are  shot  down,  their  wounds  have  undergone 
bo1  Little  change;  the  system  is  -till  Buffering 
tr.Hii  m  eertain  amount  of  nervoua  Bhock,  which 
makes  it  the  proper  time  for  effecting  ;i  thorough 

examination    without    giving    pain. 

In  these,  as  in  the  general  hospital,  there  is 
always  s  division  of  labor,  and  each  surgeon, 
knowing  his  duty,  accomplishes  the  greatest 
amount  of  work  in  his  special  department  The 
division  always  recognized,  is  the  txammiry  the 
operator,  and  the  dresser.  Those  who  are  most 
skilled  in  these  various  departments  are  expected 
v.-  ill.-  benefit  of  their  *kill  and  experience 
to  the  wounded.  More  importance  is  placed  upon 
these  subdivisions  of  labor  than  we  would,  at 
lir>i  sight,  recognize.  It  is  well  known  that 
many  hands  can  be  efficiently  worked  by  one 
head,  and  that  when  a  Burgeon  of  much  expe- 
rience .uid  mature  judgment  determines  what 
course  should  !»<•  pursued,  then'  arc  many  com- 
petent to  carry  out  bis  suggestions,  who  were 
not  sufficiently  prepared  t»>  establish  a  thorough 
diagnosis  ami   foresee  the  probable  i>>uc. 

The  importance  of  examining  a  wound  as  sel- 
dom a-  possible  being  acknowledged,  it  is  easy 
to  understand  why  tin-   most   proficient  Buxgeoua 


BRD&SfAK    MEDICAL    ORGANIZATION.  113 

in  the  service  should  be  appointed,  as  diagnos- 
ticians, to  examine,  thoroughly,  the  wounded, 
and  determine  upon  a  course  of  treatment.  In 
gunshot  wounds,  above  all  others,  the  necessity 
for  accurate  diagnosis  becomes  imperative,  and 
this  first  examination  should  never  be  slurred 
over,  however  urgent  the  demands  upon  the  sur- 
geon's time.  Except  m  very  obscure  cases,  a  second 
examination  should  never  be  made,  as  it  always  gives 
pain,  increases  irritability,  heightens  inflammation 
and  permits  air  to  gain  access  to  the  very  depth 
of  the  wound,  which  is  sure  to  promote  the  de- 
composition of  the  exudates  around  the  wound, 
with  its  suppurative  and  sloughing  sequelae.  Many 
a  Unib  and  Ufe  would  in'  preserved  wen  it  possible  to 
initti  the  examination  of  thu  wounded  to  //><  field  in- 
jbrmary.  Let  it  be  remembered,  that  the  first 
examination  is  always  less  painful  and  dangerous 
than  any  subsequent  one.  All  surgeons  agree 
upon  the  success  of  primary  operations,  when 
compared  to  secondary,  after  inflammation  has 
set  in.  How  lo  proceed  or  what  wounds  to  con- 
demn requires  nice  discrimination,  hence  the 
necessity  of  devoting  the  talent  and  experience 
<>i    the  staff  to  this  very   important   duty. 

In  the  Prussian  service,  tie'  regimental  surgeons 
oncentrated  in  groups'  with  their,  assistants, 
lo 


1U  I'KI  ssiAN    MKDIC'AL   OROANIZAXIOMj 

rather  than  follow  their  respective  regiments  into 
i  1m-  tin-.  Thus,  much  time  Lb  saved  ami  the 
wounded  receive  more  attention;  and  keeping 
tlicin  together  in  this  way,  renders  it  easy  to 
command  medical  service  wheu  it  may  be  needed 
for  any  special  extra  doty.  This,  of  course,  does 
not  prevent  Burgeous  being  sent  to  various  points 
of  the  line,  to  assist  the  medical  portion  of  the 
sanitary  corps  in  the  proper  transportation  of 
the  wounded.* 

In  tin  smu,  service,  the  primary  dressings  fur  ikt 
wounded  an  carried  bg  each  soldier,  so  thai  all 
-arv  bandages  are  on  the  spot,  and  no  time 
is  lo.-t  waiting  for  the  bandage  boxes  or  boa* 
pita!  stores.  The  general  plan  adopted  by  the 
•  •utile  army  is  as  follows:  Every  soldier  oath 
rifs  a  small  package,  three  inches  Long  and  one 
inch  thick,  which  contains  the  following  articles, 
vi«:  two  pieces  of  old,  soft,  clean  linen,  nine 
inches  Bquare;  a  piece  of  oiled  silk  or  india- 
rubber  tissue,  nine  inches  Long  by  five  inches 
wide;  a  small  ball  of  lint;  a  t)andage  two  and 
a  half  yards  long  and  two  inches  in  width.  One 
piece  of  ih,.  linen  i>  folded  double  and  rolled 
tightlj  over  the  lint,  and  over  this  the  piees  o£ 
oiled   silk    is    rolled,    the    bandage    rolled   around 


*  I,<rfflei\     Behaodlun  usswnmfe;    Berlin    1859. 


PRUSSIAN    MEDICAL    ORGANISATION.  115 

this,  and  the  whole  enveloped  in  the  second 
piece  of  linen  and  fastened  with  two  pins.  This 
should  be  put  in  a  particular  place  in  the  knap- 
sack, where  it  can  always  he  found.  Should 
there  he  two  wounds,  the  oiled  silk  and  cloth 
may  be  divided  to  make  a  douhle  dressing,  and 
one  piece  of  cloth  may  be  used  by  the  surgeon 
as  a  towel.  In  this  small  hut  very  useful  pack- 
age is  found  the  requisite  dressings  for  every 
gunshot  wound.  It  saves  the  surgeon  the  an- 
noyances and  delays  incidental  to  the  transpor- 
tation of  hospital  stores.  In  the  light  field  in- 
firmaries, nearly  all  the  dressings  of  the  wounded 
are  obtained  from  this  individual  package — the 
very  few  extra  articles  needed  b&ng  furnished 
from   the   infirmary  supplies. 

Stromyer,  in  his  surgical  writings  on  the  Schles- 
wig-Holstein  war,  speaks  of  the  medical  depart- 
ment of  the  armv  as  modelled  upon  the  military. 
Besides  the  regimental  surgeons,  each  brigade  had 
a  brigade  surgeon  with  three  assistants.  The 
larger  divisions  of  the  army  were  equally  sup- 
plied with  superior  medical  officers  and  staff! 
On  the  battle  Held  the  surgeons  of  the  army 
established  infirmaries  for  the  immediate  cars 
of  the  wounded,  who  were,  after  the  first  dress- 
ings, sent    into  the    more    permanent  infirmaries. 


116  PECULIARITY    OF    MODERN     WARFAH*. 

In  the  Confederate  service,  where  30  small  :i 
surgical  staff  is  recognized,  we  are  compelled  to 
take  advantage  of  the  railroad  facilities  of  trans- 
portation, ami  establish  hospitals  in  those  cities 
contiguous  to  the  seene  of  encounter,  under  the 
care  of  hospital  surgeons.  This  will  not  diminish 
the  arduous  duties  of  the  regimental  surgeons 
and  their  assistants,  who  will  find  constant  sow 
ploymenl  whilst  in  eamp  and  on  the  Wattle  field; 
in  spile  of  their  unceasing  efforts,  the  wounded 
•  ■annot    hut   be  wofully  neglected. 

Modern  warfare,  in  introducing  arms  of  pre- 
cision, of  immensely  increased  range,  and  per- 
fected instruments  of  destruction,  has  created  a 
new  era  in  military  Burgery*  The  conical  hail 
of  double  weight  has  become  the  common  mis- 
sile, and  when  discharged  from  a  rifle  it  Hies 
with  fearful  velocity.  Such  halls,  when  Irav- 
ersing  soft  parts,  produce  extensive  destruction, 
hut  seldom  hury  themselves.  Comparatively  few 
of  these  are  io  he  extracted  alter  a  battle. 
Should  they  impinge  upon  a  hone,  the  split- 
ting and  crashing  is  extensive;  large  spicules 
are  driven  in  every  direction,  transfixing  limbs, 
and  even  impaling  those  standing  in  the  neigh- 
borhood. In  Crimean  experience^  a  serious 
wound  was  sometimes   inflicted   by  a  large  frag* 


1 'I -TIES    OP   A    HOSPITAL    SURGEON.  11( 

incut  of  bone  driven  from  a  neighboring  sol- 
dier. The  extensive  injury  to  bones  necessi- 
tates  more  frequent  amputations  and   resections. 

This  conical  ball  seldom  fails  to  take  the 
shortest  cut  through  a  cavity  or  Limb,  and  it 
has  at  times  been  seen  to  pass  through  the 
bodies  of  two  men  and  lodge  in  that  of  a 
third.  Those  who  compare  the  dead  on  recent 
battle  tields  with  those  of  former  wars,  are 
painfully  struck  with  the  greater  mutilation  of 
the  bodies  from  conical  halls.  Rarely  are  they 
defleeted  from  their  course,  as  is  the  round  hall, 
which  is  turned  by  every  little  obstacle,  and 
takes  up  a  position  at  striking  variance  with 
any  rule  of  propulsive  forces.  In  steady  hands 
frightful  wounds  are  produced  by  the  Minic 
bail,  which  require  all  the  resources  of  surgery 
to  manage  successfully. 

Let  us  now  define  the  duties  of  a  surgeon  in 
the  Confederate  service,  in  the  hospital,  in  camp, 
and   on    the   battle   field. 

Duties  ok  a  Hospital  Surgeon. — The  surgeon 
is  the  recognized  head  of  a  military  hospital, 
and  is  responsible  for  the  organization  and 
proper  keeping  of  the  same.  When  soldiers 
enter  such  an   hospital,   all   control   from  without 


11*  PUTJES   OF   A    HOSPITAL   SURGEOJ*. 

i-  suspended,  and  regimental  officers  arc  not  al- 
lowed to  interfere  in  any  way  with  the  manage- 
ment of  the  case.  The  s«rgeon  distributes  the 
patients  according  to  convenience,  and  the  nature 
of  their  complaints,  into  wards  under  the  parti- 
cular charge  of  assistants,  and  visits  them  each 
day  as  often  as  the  state  of  the  sick  may  re- 
quire, accompanied  by  the  assistant  steward  and 
nurse.  He  keeps  the  proper  register  of  the 
hospital  and  directs  the  prescription  and  diet  of 
the  sick,  superintends  the  preparation  <»f  the  re- 
ports,  records,  pay  rolls  and  descriptive  lists, 
and  also  keeps  a  constant  supervision  over  the 
dispensary,  instruments,  medicines,  and  hospital 
stores,  as  also  over  the  hospital  expenditures, 
and  the  preparation  of  the  requisitions  and  re- 
turns, lie  keeps  an  order  and  letter  book,  in 
which  is  preserved  copies  of  all  requisitions 
and  invoices,  as  well  as  all  orders  and  letters 
relating  to  his  duties.  He  makes  a  monthly 
report  to  the  Medical  Director,  and  a  quarterly 
report  to  the  Surgeon-General,  ot  the  sick  and 
wounded  ;md  of  deaths,  and  also  of  certificates 
for  discharges  from  disability.  He  will  also  pre- 
pare the  muster  and  pay  rolls  of  the  hospital 
steward,  of  all  employees  of  the  institution,  and 
of    all     soldiers     in     hospital,     sick    or    on     duty. 


DUTIES   OF   A    HOSPITAL    SURGEON.  110 

detached  from  their  companies.  Should  a  sol- 
dier die  in  the  hospital,  the  surgeon  takes 
charge  of  his  effects  and  reports  the  same.  He 
■will  enforce  the  proper  hospital  regulations,  to 
promote  health  and  prevent  contagion,  by  exam- 
ining, daily,  into  the  hygeuic  condition  of  the 
hospital  as  regards  cleanliness,  ventilation,  over- 
crowding, proper  food,  eta.  He  will  require  the 
steward  to  take  due  care  of  tlie  stores  and  sup- 
plies, to  keep  a  regular  account  of  all  issues,  to 
prepare  the  provision  returns,  and  to  receive 
and  distribute  the  rations,  lie  will  require  the 
ward-master  to  take  charge  of  the  effects  of  the 
patients,  to  have  them  registered  in  a  book, 
with  the  patients'  names,  rank  and  company,  to 
receive  from  the  steward  the  furniture,  bedding, 
cooking  utensils,  etc.,  tor  use,  and  keep  a  re- 
cord of  them;  ami.  once  a  week,  to  take  an  in- 
ventory of  the  articles  in  use  and  report  to  him 
any  loss  or  damage,  and  to  return  to  the 
steward  such  articles  as  are  not  required  for 
u>c  The  surgeon  makes  requisitions  in  dupli- 
cate upon  the  medical  purveyor  for  all  medical 
and  hospital  supplies,  and  receipts  in  duplicate 
for   the   same    t<»    the   Surgeon -General.      When 

soldiers  are  discharged,  as  cured,  from  the  hos- 
pital,   or    die,    or    are    furloughcd    or    discharged 


1J(I  i.l'i  IK-    ...       \     H"<l'IT.\l.    -I    :;..|..-N. 

the  duty  of  the  Burgeon  to 
notify,  immediately,  tlie  captain  of  the  company 
to   which   the   soldier   belongs,   so   that   the  proper 

may  be  taken   which   the   necessities  of  the 

mi;i\  require.  The  surgeon  of  the  hospi- 
tal will  prepare  and  enforce  all  of  those  rules 
so  ncro-ary  in  a  well  regulated  hospital,  for 
establishing  order  and  keeping  up  a  military  or- 
ganization. 

Where  the   hospital    is    ;m  extensive    one,    the 
wards    are    allotted    to    assistant    surgeons,    who 

.•arc  of  the  sick,  and  beyond  the  general 
supervision,  which  the  surgeon  is  at  all  times 
called  upon  to  make,  he  mn\  only  visil  such 
of  special  interest,  <>r  which  require 
consultation  or  arc  seriously  threatened.  As  the 
sick  in  all  hospitals  arc  uol  able  to  consume 
the  ample  BUppl-J  of  food  which  the  (iovern- 
mciit  recognizes  as  a  ration,  and  which  is  is- 
sued to  all  soldiers,  whether  well  or  sick,  the 
surgeon  should  direct  the  steward  to  draw  from 
the  commissary  only  such  quantities  as  are  v^- 
quired  for  the  hospital,  and  to  commute  in 
money  for  the  stores  nol  drawn.  'This  surplus 
forma  a   Hospital   Kami,  an  account   of  which   the 

on    keeps,  and   which    can   I xpeuded    for 

comforts    for    the    sick,   botli    as   regards   subsist- 


('AMI-    DUTIES    OF    A    REGIMENTAL    SIKOF.OX.        121 

ence    of   hospital    furniture.      The    condition    of 
this   fond    is   transmitted,  quarterly,  to  the   Sur- 

evon-tJeneral. 

("amp  Duties  of  a  Regimental  8tjiw*e0W. — We 
have  already  shown  that  the  tiro  of  an  enemy 
never  decimates  an  opposing  arm  v.  Disease  is 
the  fell  destroyer  of  armies,  and  stalks  at  all 
times  through  encampments:  Whore  shot  has 
destroyed  ils  hundreds,  insidious  diseases,  with 
their  lone;  train  of  symptoms,  and  quiet,  noise- 
less progress,  sweep  away  their  ten  thousands. 
To  keep  an  army  in  health  is,  then,  even  more 
important  than  to  enre  wounds  from  the  battle 
fields.  But,  as  surgeons  in  the  service  are  ex- 
pected to  he  skilled  in  both  departments,  so 
that,  in  either  case,  the  troops  under  their  care 
miirht  suiter  no  detriment,  they  should  he  thor- 
oughly prepared  for  the  very  responsible  posi- 
tions which  they  till.  Conservative  surgery  re- 
quires much  more  at  the  hands  of  the  surgeon 
than  the  destructive  practice  of  former  times. 
Every  surgeon  should  now  prepare  himself  for 
the  field,  by  familiarizing  himself  with  opera- 
tive Borgery.  Halt'  knowledge  leads  into  med- 
dling, which  is  far  worse  than  no  surgical  as- 
sistance. Many  a  wounded  soldier  has  felt  heavily 
11 


.    \\ii'    hi    I  IK«    <>y    A    KKUJ  Mh.\  i  \l.    -1  RUJ 

I8y  luuid  of  tl<<    willing  surgeon  who  lacked  il-> 

g  head.  1  'In-  surgeon  has  charge  of  a  num- 
ber of  very  valuable  lives,  aud  the  necessity  im- 
posed—  by  th>-  absence  <»i  consulting  :ii»l  —  o£ 
deciding  the  most  serious  ami  critical 
upon  uia  own  unaided  judgment  demands,  upon 
part,  self-reliance,  which  ran  oulv  be  baaed 
upon    previous   preparation.      Camp   life  gives  a 

..ii  much  food  for  thought  ami  ample  per* 
-.■mil  experience,  1  m t  gives  him  no  time  to  con- 
sult authors  and  improve  himself  with  books, 
1 1,    does   not  i  great    a   variety  of  disease  - 

ati  are  uiet  with  iu  civil  practice,  but  he  has  a 
wider  tield  for  observing  the  influences  <>i  ex- 
ternal modifying  circumstances — as  exposure,  im- 
proper food,  imperfect  clothing,  irregular  work, 
want  of  cleanliness,  and  depressing  or  exhilarat- 
ing mental  influences.  Tim  diseases  of  a  soU 
dier,  Like  those  of  most  trades,  are  peculiar — 
each  trade  begetting  its  own,  whilst  it  gives 
immunity  to  others,     The  greater  unilbrmity  in 

constitution,  modes  of  living,  exposure  t<> 
similar  external  influences,  and  strut  discipline, 
modify,  to  a  considerable  extent,  the  diseases  of 
camp.  Ii  i>  especially  the  crowding  together, 
with   the   animal    emanations   from   such  a   num- 

•  >t'  living  hciugs,  that  gives  character  t<>  the 
ph.i  ••        -t   'Ii 


c'AMI'    T»I    [IKS    OF    A    RKOIMKXTAI,    SURGEON.         123 

The  preservation  of  the  heaUh  of  the  soldier  being 

ih,  sale  (hit;/  <>f  the  imUkiry  surgeon^  he  will  he 
expected  to  nee  every  means  within  his  reach  to 
attain  this  desirable  end.  and  more  especially  by 
a  rigid  observance  of  those  forms  of  discipline 
and  economy  which  arc  under  the  direction  and 
surveillance  of  the  military  officers.  As  diseases 
will  arise  among  troops,  and.  as  very  few  of  these 
cannot  he  arrested  by  means  of  art  when  skil- 
fuily  applied  at  an  early  period,  care  should  he 
taken  that  medical  skill  he  promptly  resorted  to 
at  the  very  first  sign  of  indisposition.  Hygiene 
must  first  claim  his  attention:  under  the  adage, 
"prevention  is  better  than  cure."  W  the  troops 
are  about  going  into  eamp,  lie  must  examine  the 
ground  and  see  whether  any  causes  exist  for 
rendering  the  place  insalubrious.  When  in  a 
friendly  country,  he  should  seek  information  from 
the  local  physicians,  which  will  not  only  give 
him  a  better  insight  into  the  sanitary  condition 
of  the  point  selected,  but  will  also  instruct  him 
upon  the  diseases  prevalent  in  the  locality,  and 
the  means  which  local  experience  and  observa- 
tion have  proved  most  effective  in  controlling 
such  diseases.  He  must  see  that  the  troops  in 
camp  are  supplied  with  ^\vy  straw  tor  beds,  and 
that    the?   air   the   same   with    their    tent    dailv.   so 


1      I        CAMP    Dl  -  A    RKUIMENTAL    SUROEON. 

ensure  ;i  healthy  place  for  repose,  and  re- 
port any  iHLfl«<t  to  the  commanding  officer.  He 
must  sec  thai  tip-  soldiers  are  properly  clothed, 
and  well  fed  with  wholesome  nutritions  food, 
and  supplied  with  an  abundance  <>t'  good  water, 
and,  from  time  to  time  should  BUggest  to  tin' 
commanding  officer  such  changes  in  the  diet  as 
will  In-  conducive  to  the  health  of  the  command. 
It'  the  water  is  bad,  lie  should  study  how  it  can 
be  improved,  so  as  not  to  act  injuriously  upon 
the  men.  Cleanliness  id"  the  encampment  and 
of  the  tent,  with  frequent  ablutions  of  the  body 
and  clothing  of  soldiers,  should   never  he  absent 

from   his    thoughts.      He   should    point    out    to   the 

commanding  officer  all   nuisances  which  promise 

to  he  detrimental  to  the  health  of  the  corps, 
and  xirgt  their  removal — suggesting  how  they 
can  best  he  disposed  of.  Much  of  the  sickness 
in  the   army  eai   be   attributed   to   a   dereliction 

of  this  duty  upon  the  part  of  the  medical  officer. 

The   hospital   tents   will    he   pitched    upon  a   dry. 

well-drained   spot,   if  a   building   cannot   he   ob- 

taincd  for  the  same,  and  it  is  the  duly  of  the 
regimental  surgeon  to  attend  to  the  proper  fur- 
nishing of  the  same  with  all  possible  conveni- 
ences for  the  STck.  lie  will  enforce  all  proper 
hospital   regulations  to    promote    health   and    \<w- 


(AMP    DUTIES    OF   A    BEGIMSMTAL    SUROOOCT        129 

vent  contagion,  by  ventilation.  scrupulous  cleanli- 
ness, frequent  changes  of  bedding,  linen,  etc 

At  the  morning  surgeon's  call,  the  sick  of  the 
regiment  will   he  eondacted   to   tin-  hospital    by 

the  first  aergeanta  of  the  various  companies,  who 
will  each  hand  to  the  surgeon  a-  list  of  all  the 
sick  of  the  company,  on  which  the  surgeon  will 
state  who  are  to  remain  or  go  into  hospital  ;  who 
are  to  return  to  quarters  as  sick  or  convalescent; 
what  duties  the  convalescents,  in  quarters,  are 
capable  of  pcrformimg-;  what  cases  are  feigned, 
and  any  other  information  in  regard  to  the  sick 
of  the  company  he  may  have  to  communicate  to 
the  company  commander.  lie  will  then  distri- 
bute the  patients  in  the  hospital  ;  see  that  they 
are  properly  provided  with  comfortable  beds  ; 
enter,  in  the  proper  register,  the  name,  the  east-, 
the  disease  ;  and  in  the  diet  and  prescription 
hook,  the  medicines  which  the  case  requires.  If 
his  assistant  is  not  present,  and  his  steward  is 
not  competent,  he  prepares  the  medicines  and 
superintends  their  administration.  He  will  visit 
the  hospital  each  day,  as  frequently  as  the  state 
of  tin'  sick  may  require.  Should  any  soldier  he 
taken  suddenly  sick,  his  case  is  at  once  reported 
to  the  surgeon,  who  will  visit  and  prescribe  for 
him    in    his    tent,    unless   the    case    threaten    to   he 


1  _'  I        C  IMV    Dl    !  IKS    OF     \    Ki:«.l  MEN  I  U. 

serious,    whan    he    should    be    removed    without 

<l>  \a\   to  the  hospital. 

Convalescents,  <>n  coming  oat  <>t'  the  hospital, 
•re  not  to  be  put  on  duty  till  the  surgeon  certt- 
tie<  i.i  the  commanding  officer  that  they  have 
perfectly  recovered  :  tor  which  purpose  it  i>  tin' 
duty  of  the  surgeon  to  make,  daily,  a  particular 
inspection  <»!'  these  men,  at  morning  parades  '" 
prevent  any  remaining  longer  exempt  from  duty 
than  ilif  state  of  their  health  renders  absolutely 
necessary.  Alter  the  Burgeon's  call,  he  will  make 
a   morning   report    of  all   the  BJck  and   disabled   to 

the  commanding  officer.  lie  also  recommends 
that  leave  of  absence  he  granted,  on  furlough,  to 
those  convalescents  who  will   recover  more  rapidly 

by  change  of  scene  and  life;  or  discharges  for 
those  whom  experience  has  proved  physically 
unlit    ldr   the   arduous   duties    of   camp   lite. 

The  senior  medical  officer  of  a  post,  hospital, 
regiment,  or  detachment,  will  make  monthly  to 
the    medical    director,  and  quarterly   to  the  sear* 

'ii-^eiieral.  a    report    of  the    sick    and   wounded, 

of  deaths,  and   certificates  granted   for  discharge 

from  disability,  and  transmit  to  him  the  same, 
with  n  statement  of  the  hospital  fund.  lie  will 
;d-o    keep   the    following   records,    from    which    the 

condensed   report  to  the  superior  medical  officer 


CAMP    DUTIES    OF    A    REGIMENTAL    SURGEON.        ll'T 

is  drawn,  viz :  a  register  of  patients ;  a  proscrip- 
tion book;  a  diet  book;  a  case  book:  copies  of 
his  requisitions-;  annual  returns,  and  reports  of 
sick  and  wounded,  and  an  order  and  letter  book, 
in  which  will  he  transcribed  all  orders  and  let- 
ters relating  to  his  duties.  All  requisitions  for 
hospital  and  medical  stores  must  come  from  the 
senior  Burgeon,  with  the  approval  of  tlie  com- 
manding officer,  certifying  that  the  same  are  ne- 
cessary for  the  sick,  and  that  the  requisition 
conforms  strictly  to  the  supply  table  tor  field 
service.  These  requisitions  are  drawn  out  by 
the  surgeon  in  the  proper  form,  always  in  dupli- 
cate, stating  what  medicines  are  on  hand,  and 
are  sent  to  the  Medical  Director,  or,  should 
there  be  no  one  acting  in  his  district,  to  the 
Burgeon-General.  All  stores  received  from  the 
medical  purveyor  must  be  receipted  for  in  dupli- 
cate to  the  Surgeon-General,  by  the  senior  siir- 
u'con,  who  also  notifies  the  medical  purveyor  of 
their   reception. 

The  duties  of  //><   assistant  sturgeon  are  very  simi- 
lar, in  many  respects,  to  those  of  the  surgeon.      If 

he  has  the  confidence  <>f  the  regimental  surgeon, 
the  patients  arc  equally  divided  between  them: 
be    treating    a    certain    number  of  sick   ordinarily 


f'AMP    II  TIK>    OF    A     HKiiniCNTAI.    STROKOX. 

without  interference  from  the  senior  Burgeon,  ex- 
cept they  be  serious  cases,  when  be  seeks  advice 
from  the  regimental  surgeon.  Although  this  is 
the  common  course  pursued,  it  is  not  so  from 
right,  1-ut  by  suffierance  of  the  senior  surgeon.  In 
the  army  regulations  the  senior  surgeon  being 
the  superior  officer,  the  assistant  surgeon  is  under 
liis  control.  lie  is  supposed  to  do  merely  the 
medical  duties  when  the  surgeon  is  present — that 
is  to  say,  making  up  medicines,  seeing  that  the 
patients  get  them  at  the  proper  time,  apply  dress- 
ings, bandage  fractured  limbs,  keep  the  register, 
diet  and  prescription  hooks,  and  assist  in  com- 
piling the  monthly  and  quarterly  returns*  When 
a  Attachment  is  sent  oil'  upon  special  service, 
the  assistant  surgeon  accompanies  it  as  medical 
officer. 

When  epidemics  occur  in  camp,  then  the  du- 
ties of  the  medical  officers  become  very  arduous  ; 
the  daily  and  nightly  toil  which  they  are  com- 
pelled to  undergo,  the  fatigue  of  body  and  anxiety 
of  mind  which  is  their  daily  routine,  soon  breaks 
1  hem  down,  and  many  an  over-zealous  surgeon 
becomes  a  prey  to  the  diseases  which  his  con- 
stunt  efforts  are  trying  to  subdue  in  others.  This 
is  particularly  the  case  when  typhus  is  raging  in 
camp:   when   a   neglect  of  those  hygienic  precau- 


CAMP    DUTIES    (IF    A     I!K(!1MI'NTAI,    SURfiEONF.        12fl 

tions  which  the  medical  officers  are  instilling 
into  the  men,  causes  many  a  victim  in  the  medi- 
cal ranks.  Under  such  conditions,  it  becomes  as 
imperatively  the  duty  oY  the  surgeons  to  take 
care  of  themselves  as  to  attend  to  the  sick:  for, 
should  they  needlessly  sacrifice  their  lives,  they 
entail  severe  suffering  on  their  regiments.  The 
Crimean  surgeons  were  severely  censured,  after 
spending  all  day  in  the  typhus  and  cholera  hos- 
pitals, with  their  tainted  atmospheres,  for  re- 
maining there  during  the  night  also,  when  there 
was  no  necessity  tor  it.  It  was  a  useless  and 
dangerous  imprudence,  an  exaggeration  of  duty, 
which  deprives  the  army  of  well-informed  men, 
and  impairs  the  utility  of  the  service. 

In  the  Crimea,  the  surgeons  would  frequently 
meet  together  lor  scientific  conference  and  for 
mutual  instruction.  Hate  each  gave  his  expe- 
rience, and  compared  the  results  o\'  different 
methods  of  treatment.  Their  meetings  always 
terminated  in  practicing  amputations,  resections, 
and  the  ligation  of  arteries  on  the  dead  subject. 
'flic  object  of  this  was  not  Only  to  gain  dexterity 
in  the  operative  manual,  hut  also  to  find  out 
who  were  the  most  skilled,  and.  therefore,  most 
worthy  of  being  intrusted  with  important  du- 
ties.     It    is   said    that    the  mortality   of  the  armv 


1"0  DUTI  is.  N     P.  A  TTI.i.    I!  Ill' 

amounted  t->  two  hundred  per  day,  which  wave 
ample  materia)  for  such  practice.  These  meet- 
ing, vi  ere  presided  over  by  one  of  the  highest 
-i.iil'  surgeons  or  medical  directors,  who  would 
often  deliver  to  the  society  practical  lectures 
upon  the  treatment  <>f  gunshot  wounds.  This 
plan  might  be  carried  out  in  all  armies,  as  it 
musl  redound  to  the  benefit  of  both  surge 
and  patients. 

I  > ;    !  I  i :  -  <U    1MB  Si  EUJBOH  ON  Till!   BATTLE  KlKLI). — 

The  common  fear  which  depresses  the  soldier 
on  tin-  eve  of  a  battle,  more  than  any  other,  is 
inn  so  much  death,  but  the  dread  of  mutilation. 
Ballets  an-  neither  respecters  of  parts  nor  per- 
:-.  and  the  prospect  of  Losing  an  eye,  an  arm 
Off  leg,  makes  many  a  brave  man  quail  before  the 
oi'di-al  (through  which  he  is  to  pass.  So  that 
bafopt  a  battle  there  is  a  vague,  uneasy  restless- 
iii-ss — a  foreboding  of  coming  evil,  which  takes 
p()»es>i<iu    of  the    bravest,    and    cannot    be   driven 

oil'  except  by  the  commencement  <>f  the  tight. 
The  early  booming  of  cannon  braces  all  for  ac- 
tion; all  thoughts  of  fear  <>r  self  are  now  dis- 
carded, the  demon  of  war  rules  triumphantly 
^  over  the  assembled  host,  aud  suppresses,  through 
for    blood   and    desire    for    victory,    all   de- 


DUTIES    OF    SURGEON    ON    BATTLE    FIELD.  131 

pressing  influences.  There  is  something  in  the 
smell  dt"  gunpowder  which  makes  men  forget 
their  origin;  by  its  magic  spell  women  are  made 
brave,  and  cowards  heroes.  In  the  eagerness  of 
the  fray,  an  intoxication  guides  all  to  acts  of 
daring.  Who,  in  his  sober  moments,  would 
walk  no  to  the  mouth  of  a  loaded  cannon  to 
which  a  torch  is  being  applied  ':  Yet,  on*  the 
battle  field  find  the  man  who,  at  the  word  of 
command,  ami  whilst  under  the  stimulating  in- 
toxication from  gunpowder,  would  not  face  cer- 
tain destruction  !  Fortunate  it  is  that  nature  has 
so  constituted  us,  or  the  terror  of  pursuing  what 
duty  dictates  would  be  agonizing  indeed.  The 
surgeon  on  the  battle  field  must  participate  in 
the  dangers,  without  the  stimulation  of  the  con- 
flict: he  requires,  therefore,  a  double  proportion 
of  courage  to  sustain  him  in  the  trying  part 
which   he  has  to  perform. 

Upon    the    eve  of  a    battle,    the    regimental    sur- 

geon  has  much  to  do  to  prepare  facilities  for 
the  treatment  of  the  wounded.  lie  must  see 
that  the  hospital  stores  are  brought  up  with  the 
ammunition  wagons — as  the  articles  for  treating 
ihc  wounded  and  saving  the  life  of  comrades, 
are  fully  as  important  as  those  for  the  destruc- 
tion of  the  euemy,      lb'  examines  his  store-,  and 


132  DUTIES    OF    SURGEON    ON     HAITI. I      FIELD. 

himself   thai    nothing  which   will   be   iv- 
quired  for  the  wounded  has  been  omitted  or  for- 
gotten,    lie  examines  his  instruments,  his  supply 
of  bandages,  lint,*  india-i'ubber  cloth,  or  oiled  or 
•  I    -ilk,   etc:    the   rale   m  1 « »] >t *•<  1   in   European 
armies    being  to    haw   ready   dressings   for  one- 
tilth    of    ihf    command    going    into    action.      Ho 
thai    chloroform   and   opium,    the   main  sup- 
of  the    wounded,    are    at     hand    in    sufficient 
ijuantitv.      Water   he    has   nol    overlooked,  M 
abundant    supply    will    be    needed    to    meet    the 
incessant,    ii 1 1 1 ii i t i gat ed    thirst    <'t'    the    wounded. 
lie  ihonld  be  well  sup]. lied  with   astringent 

baa    been  used    in    military    surgery, 

Crimea    i-  I    substitute   for  lint    l>y 

as,  with   whom  an  abundance  of  lint   it 
«••»    in    tin'  rands.      \-    ii   can   be  .-"  easily  obtained 

m  .lu\    pari   oj    i li>    Confedera  and   al   bo   trifling    a    cost,   it 

promisee    Bpecdily    t"    usurp    the    place    of    the   officinal    preparation. 
.\"«    thai    tents   and    meehea   are  scarcely    aeed,  and    receptacles   lb» 

I  in  d        .1  surgical  practice,  wo 
reason    why   carded   cotton,   with   its    pi  would 

i  ::  ih  in  lint,  whi<  mi  med 

ard   Lb  roads,   whioh  would   leave   their  mark-  upon  a  .-v\>- 
a  flamed  surface,  and,  therefore,  must  be  the  unrecognized  cause 
'in. 

,    in    bis   work,  "Bandagea     i    appareil  k   pansoment,"  after 
thai   the   a  i   ha  1   been  I    with- 

in atmei  t    "i    woun  -i  1*1    lie 

tor,   thai    fur   from    being   lnutful, 
t,         loft,    to  clean,   bo   t  infple,  bo   abundant, 
sd,   is   the   roi 

for  protecting  part's    from    pressure,   and 
oalittag    the    |  re-  in.-  of  tin    apparatus,  tliis  is  the   preferable 


DUTIES    <>F    SURGEON    ON    BATTLE    FIELD.  133 

which  the  per  chloride  or  per  sulphate  of  iron 
is  the  best  to  control  annoying  hemorrhage. 
He  should  also  have  a  moderate  supply  of 
brandy  to  revive  those  exhausted  from  hemor- 
rhage, oil  to  grease  their  wounds;  and  a  little 
tea.  sugar,  ami  such  medical  comforts  as  will 
refresh   and   support  the  wounded. 

Having  selected  from  the  general  stock  those 
articles  which  he  will  need,  such  as  all  articles 
for  dressing,  as  cotton,  lint,  cloth,  bandages, 
oiled  silk,  sponges,  ligatures,  adhesive  plaster, 
splints  tor  treating  all  varieties  of  fractures,  am- 
putating   and    dressing    instruments,    with    medi- 


article  for  many  reasons.  Now  for  the  dressing  wounds  lint  is  used; 
ii  is  thought  soft  and  soothing  to  the  raw  surface — how 
much  better,  on  this  very  account,  is  ootton  over  the  Buesl  lint.  If 
cotton  is  used,  ami  its  claims  recognized  as  an  Application  to  the 
raw,  inflamed,  sensitive  surface  of  a  barn,  with  how  much  more 
reason  could  ii  be  applied  to  the  comparatively  healthy  surface  of 
a  wound.  The  best  lint  i<  obtained  by  scratching  doth  until  it 
yields  a  sofl  down,  which,  when  obtained,  is  nothing  but  raw  ootton, 
viz:  reducing  the  oloth  to  its  primitive  element.  Hereafter,  there 
■will  not  be  that  demand  for  lint  as  heretofore;  ami  in  limos  of  war, 
the  female  population  of  a  country  will  not  be  called  upon  to  use 
all  of  their  exertions  in  scraping  lint  from  rags,  many  of  which 
:iiv  :i .1  v  contain  the  germs  of  disease,  when  :niy  number  of  bales 
■  i  lint  i : 1 1 1  be  obtained  al  ence,  and  at  little  expense,  and 
without  trouble.  Female  labor  can  l>o  more  profitably  employed. 
Much  can  also  he  said  of  new  cloth  versus  the  old  linen,  of  timp- 
d  reputation.  Suffice  it  to  say,  in  this  connection,  that  an 
army  should  •ever  clog  its  movements  bj  an  excess  of  baggage, 
and  that  the  old  linen  (which  ean  be  osed  but  onoe)  required  for 
an  army  is  no  Bmall  item.  New  cloth  can  be  washed  a  doccn  time«, 
if  repaired,  wliieli   in  Itself  i  recommendation. 


]::  |  pan  mi 

oines  and  stimuli,  and  a  fall  Bupply  of  good 
water,  they  are  carefully  put  upon  ;i  pack-mule 
in  two  strong,  iron-bound  boxes,  catted  panniers. 
oiH-  hanging  on  either  side  of  the  saddle  One 
i-  usually  devoted  to  medicines,  the  other  is 
used  for  dressing  apparatus.  'Phis  distribution 
Lrivoa  the  surgeon  greal  facility  in  moving  about 
the  field  to  where  his  services  may  be  moel  re- 
quired, whilst  it  dispenses  with  the  hospital  store 
wagon,  which  is  altogether  too  cumbersome  to 
follow  light  troops  in  their  varied  and  active 
movements.  In  European  armies  every  regiment 
has  such  a  pannier,  w  1 1 i .  1 1  is  continually  resup- 
plied  from  the  medical  store  wagons.  The  com- 
manding general  may  sometimes  have  good  rea- 
sons, under  particular  circumstances,  for  orderiug 
ihe  medical  wagons  to  remain  behind  with  the 
baggage :  then  the  conveyance  of  all  needful 
medical  supplies  for  the  wounded  on  packvhorses, 
becomes  imperatn  e. 

panniers  are  sometimes  objected  to  on  ac- 
count of  their  >i/e.  and  as  modern  surgery  re- 
cognises  bul    few   medicines   as  really   necessary 

on  the  field,   lighl    leather  wat erproof  eases,  which 

are  earried  by  an  orderly,  are  found  preferable. 
A  LTeat  convenience  to  the  surgeon^  is  the  mod- 
ern addition  of  a  hospital  knapsack  to  his  equip- 


HOSPITAL    KNAPSACK.  131 

meats,   which    enables  hw  orderly  to  carry  con* 

venientiy,  tor  immediate  nsi\  the  1  mm v  articles 
-which  attendance  upon  the  sick  require.  The 
hospital  knapsack  in  use  in  the  Federal  army 
is  made  of  basket-work,  about  three  times  the 
size  of  an  ordinary  army  knapsack.  The  divis- 
ions in  its  interior,  which  are  entered  from  the 
side,  contain  tin  cans  for  drugs.  The  knapsack 
when  empty  weighs  six  pounds,  and  when  filled 
with  the  following  ingredients,  eighteen  pounds* 
The  contents  are  as  follows:  Castor  oil,  1  <{t.; 
simple  cerate,  1  11).:  chloroform,  4  oz.:  fluid 
extract  of  ipecac,  4  oz.;  conip.  cathartic  pills,  4 
doz.:  blue  pills  (5  grains  each),  2  doz.:  opium 
pills  (I  grain  each),  2  doz.:  comp.  opium  pills 
(opium  1  grain,  camphor  -  grains),  4  doz.:  <pii- 
nine  pills  (3  grains  each).  4  doz.:  iod.  potassium, 
1  oz.:  snlph.  quinine,  I  oz.;  comp.  spirits  of 
;ether,  4  oz.:  turpentine,  4  oz.;  laudanum,  4  oz.; 
paregoric.  6  oz.;  snlph.  zinc,  1  oz.;  nit.  silver, 
\  oz.;  alum.  2  oz.;  isinglass  plaster,  2  yds.;  ad- 
hesive plaster,  2  yds.;  lint  J  11>.:  sponge.  2  pieces; 
fandages,  4  doz.;  Ilannel,  2  yt\*.;  hinders'  hoards, 
No.  4.;  field  tourniquet,  1;  lead  pencils,  2 ; 
note  paper,  1  qr.;  paper  pins,  1  :  tape,  I  piece. 
In  making  the  daily  rounds  of  the  sick  in 
camp,  wh&U   they  are  scattered   in   their   tents  and 


HOSPITAL    KJ 

qoI  concentrated  within  an  kospital  enclosure, 
fcbis  knapsack  with  contents,  carried  by  an  orderly 
or  the  hospital  steward  of  the  regiment,  will  sarve 
mack  delay  and  trouble  in  the  dispensing  of 
drugs.  When  carried  on  the  battle  field  many 
articles  may  be  dispensed  with,  and  in  their 
stead  the  knapsack  should  contain  lint,  bandages, 
adhesive  plaster,  sponges,  and  a  bottle  of  sweet 
oil,  with  pins  and  tape,  for  the  dressing  of 
wounds,  a  bottle  of  the  per  chloride  of  iron  for 
controlling  hemorrhage,  field  tourinquets,  ■  hot- 
tic  of  morphine  for  allaying  pain,  chloroform, 
should  an  urgent  case  demand  an  immediate 
operation  to  save  lite,  and  a  quart  br  more  of 
brandy; — also  eandles  and  matches,  which  are  in- 
disp<  nsable,  as  no  efficient  aid  can  be  given  to 
the  wounded  upon  the  field  after  darkness  Bete 
in.  without  them.  The  orderly,  who  carries  the 
knapsack,  also  carries  suspended  to  his  person 
a    large  canteen,   three  times   the   ordinary   size, 

tilled  with  water,  and  also  a  tin  cup.  The  knap- 
sack should  he  so  arranged  that  all  the  contents 
will  he  exposed  to  view  without  unpacking. 
The  mi.'  which  has  hecn  issued  to  the  Confed- 
erate army  is  framed  similarly  to  ihe  ordinary 
knap-ack.  hut  larger,  being  sixteen  inches  hum-, 
fourteen    inches   wide,   and   six   inches   deep.      The 


DUTIES    OF    SURC.EON    ON    » ATT  LB    FIELD.  1H7 

interior  is  divided  by  wooden  partitions,  into 
four  compartments,  with  a  broad  band  of  leather 
lacked  across  the  lower  portion  of  the  enclosure 

to  prevent  the  contents  from  dropping  out.  A 
leather  apron,  similar  to  that  of  an  ordinary 
knapsack,  covers  the  front  of  the  knapsack. 
The  frame  is  surmounted  by  a  horseman's  valise, 
which  is  convenient  for  carrying  large  bottles, 
dressings,  and  instruments.  Assistant  surgeons 
should  carry  a  small  leather  haversack,  with  a 
Hap  cover,  to  button  for  security.  This  will 
contain  his  pocket  instruments,  torsion  forcepts, 
light  dressings,  pins,   sponges,   etc. 

If  the  krmy  would  adopt  those  regulations  of 
the  Prussian  service,  which  compel  every  soldier 
going  into  battle  to  carry  in  his  knapsack  a 
small  bundle  of  dressings,  prepared  according 
to  a  formula,  then  the  hospital  stores  could  in 
a  great  measure  be  dispensed  with,  and  with 
few  additions  to  the  individual  stock,  the  wound- 
ed could  receive  careful  dressing.  The  instru- 
ments and  few  medicines  which  the  infirmary 
would  require,  could  then  be  readily  moved 
troiii  place  to  place,  following  the  line  as  the 
din  of  battle  recedes  from  the  points  where  the 
tight  had  commenced. 

The  surgeon  should  examine  the  means  of 
12 


138  amiii  i.am'k  ooaPi 

transporting  the  wounded  from  where  they  tall 
t"  the  field  infirmary.  These  should  consist  of 
at  least  two  stretchers  for  every  one  hundred 
men  engaged,  although  in  European  armies  four 
are  allowed  to  each  company,  besides  light  am- 
bulance wagons,  spring  carts,  or  any  other  con- 
veyance of  transportation,  bo  accommodate  in 
the  proportion  of  forty  persons  for  every  one 
thousand  troops.  The  allowance  of  ambulaucea 
in  the  Confederate  service,  is  for  twenty  lying 
and  twenty  Bitting  per  our  thousand  men.  As 
there  is  no  distinct  organization  <>t'  an  ambu- 
lance corps,  but  ten  litters  are  issued  to  each 
regiment,    the    carriers    being   taken    from    the 

rank-. 

The  character  of  the  transport  service  will  de- 
pend upon  the  character  of  the  country  in  which 
the  war  is  carried  on.  In  a  level  country,  wag- 
ons are  the  most  serviceable,  whilst  in  hilly 
localities,  litters  carried  by  mules  would  lie  the 
most  comfortable  transportation  for  the  wounded. 
In  European  armies,  a  distinct  body  of  men  are 
employed  for  conveying  the  wounded,  so  that 
practiced  hands  may  soothe  the  agonies  of  trans- 
portation. This  is  by  far  the  most  humane 
course,   ami  a<   a    mark  of  civilized  warfare  should 

he  of  universal  adoption.     It  is  highly  important 


DUTIES    OF    SURGEON    ON    BATTLE    FIELD.  139 

that  a  similar  body  be  instructed  to  act  as  nurses 
as  well  as  attend  immediately  upon  tlic  wounded, 
as  this  timely  assistance  may  save  many  lives  on 
the  field.  In  those  armies  in  which  this  amlm- 
lanee  corps  has  not  yet  heeii  introduced,  the 
regimental  quartermaster  in  charge  of  the  pio- 
neers and  musicians,  form  a  temporary  body  o\' 
earners.  Besides  the  litters,  each  bearer  carries 
a  canteen  full  of  water,  and  the  assistant  sur- 
geon,  who  follows  the  litters  and  directs  the 
transportation,  is  accompanied  by  two  men  as 
orderlies.  One  of  these  orderlies  who  habitually 
follows  the  medical  officer,  whether  in  hattle  or 
on  the  march,  carries  the  hospital  knapsack. 
One  of  the  orderlies  is  armed  to  protect  the 
party  against  stragglers  and  marauders.  The 
surgeon,  for  a  similar  reason,  should  he  also 
armed  with  a  revolver.  The  orderlies  assist  the 
surgeon  in  niacins  the  wounded  carefully  in  the 
wagons;  and  also  following  them,  are  at  hand 
to  assist  in  unloading  the  wagons  at  the  field 
infirmary. 

When  the  troops  deploy  or  form  for  action, 
the  surgeons,  with  their  assistants  and  pack- 
horses,  move  a  short  distance  to  the  rear  out  o|' 
the  range  of  the  shot,  and  they  establish  there 
the   tield    infirmary.      It    would    he    convenient    if 


140     DUTIES  OF  SURGEON  ON  BATTLE  FIEI.D. 

some  house  could  be  used  for  this  temporary 
hospital. 

WTiere  this  cannot  be  had,  the  shade  of  trees 
or  the  shelter  of  :i  bill-side,  will  answer  the 
temporary  wants  of  the  Burgeon.  If  the  body  of 
troops  about  entering  into  battle  is  a  large  one, 

with    an    extended    line,    several    of    these    points 

should  he  selected  and  marked  l>v  a  suitahle  yel- 
low Sag,  which  designates  the  spot  where  those 
slightly  wounded  ean  seek  surgical  aid.  These 
Locations    should   he    selected    as    near   as    possible 

to  the  line  of  battle,  so  that  they  may  he  easily 
reached  by  the  wounded.  They  should  he  readi- 
ly recognized,  protected  from  the  enemy's  tire, 
well  supplied  with  water,  and,  if  possible,  straw 
and  shelter  for  the  wounded.  These  sites  should 
he  known  to  the  commanding  officer,  so  that  he 
mi-lit  extend  his  orders  to  the  infirmary,  should 
it   he  necessary,   daring  the  fight. 

Before  the  medical  army  stall'  was  properly 
Organized,  and  their  plan  of  work  studied  so  as 
to  render  the  stall'  most  efficient,  surgeons  ac- 
companied the  troops  into  the  lire  and  took  po- 
sition along  the  line  of  hatt'ic  where  they  could 
give  immediate  succor  to  the  wounded.  Expe- 
rience Bhowed  them  that,  thus  isolated  from 
each    other,    and     taring    no    means    of    Dairying 


DUTIES    OF    SURGEON    ON    BATTLE    FIELD.  141 

■with  them  the  various  instruments  which  they 
would  require^  it  was  impossible  to  perform  any 
but  the  most  trivial  operations,  hence  the  neces- 
sity of  assembling  surgeons  together  at  the  va- 
rious field  infirmaries,  where,  by  assisting  each 
other,  all  the  necessary  operations  may  be  suc- 
cessfully undertaken.  Instead  of  each  regimen- 
tal surgeon  establishing  such  for  his  regiment, 
it  would  be  much  better  if  they  would  concen- 
trate for  individual  assistance,  when  the  wound- 
ed would  receive  more  attention,  and  the  work 
of  dressing  would  be  much  expedited. 

When  surgeons  combine  at  the  field  infirma- 
ries, the  usual  course  is  to  be  operator  and  as- 
sistant in  turn — relieving  each  other  when  fa- 
tigued. It  would  be  far  better,  however,  to  es- 
tablish at  once,  if  possible,  a  division  of  labor; 
let  there  be  an  understanding  that  those  best 
adapted  by  experience  to  undertake  certain  du- 
ties, should  confine  themselves  strictly  to  the 
same.  When  each  one  knows  what  roll  he  is 
to  play,  and  does  not  interfere  with  others,  a 
great  deal  more  work  can  be  accomplished  than 
where  each  one  acts  independently  for  himself. 
The  force  of  this  will  appear,  when  it  is  remem- 
bered that  all  experience  shows  the  medical 
siatf  of   an    army,    however   numerous,    to  be  al- 


142        ourres  op  buroeon  on   battlk  field. 

ways  boo  few  on  battle  days.  Remember,  thai 
nil  tin  wounded  must  undergo  a  thorough  eramina- 
and  ,ill  needful  operations  must  Ik  -performed 
within  twenty-four  hours,  or  the  wounded  suffer 
from  neglect.  Now.  take  into  consideration  the 
very  sinnll  surgical  staff  of  dot  army  and  the 
accuracy  of  fire  of  the  contestants,  with  the  most 
approved  and  destructive  anus  with  very  long 
range,  and  we  will  immediately  see  the  neces- 
sity of  economizing  time  and  labor. 

The  movements  and  position  of  the  troops 
and  the  character  of  the  ground,  must  establish 
the  necessity  for  the  greater  or  less  concentra- 
tion of  surgeons  at  the  field  infirmaries.  As  the 
troops  advance,  they  are  followed  by  the  hands- 
men  or  hearers,  and.  it'  the  country  permits  it, 
the  ambulance  wagons,  under  charge  <>f  the 
quartermaster  and  assistant  Burgeon  with  his  or- 
derlies. They  station  themselves  in  the  rear  of 
the  advancing  line,  where  they  can  distinctly  see 

what  happens,  and  remove  immediately,  with- 
out the  range  of  the  shot,  those  who  may  fall 
wounded.  It  is  imperatively  demanded,  on  the 
SCOre  of  humanity,  that  the  wounded  he  re- 
moved from  the  field  of  battle,  with  as  little 
d<  ia\  ;.-  possible,  for  early  treatment.  In  gun- 
shot    wounds,  above  all  others,  to  obtain  success, 


DUTIES    OF    SURGEON    ON    BATTLE    FIELD.  14:} 

early  surgical  assistance  is  of  the  greatest  mo- 
ment: ami  in  many,  as  in  chest  wounds,  the  omis- 
sions on  the  battle  field  immediately  after  the 
injurv  is  received  are  never  made  up,  with  what- 
soever diligence  and  skill  the  after-treatment  is 
pursued.  Therein  is  the  great  advantage  of 
having  a  special  transport  corps,  otherwise  the 
excitement  of  battle  or  the  eagerness  of  pursuit 
carries  the  line  to  a  distance  from  the  ground 
where  the  battle  first  commenced;  and  it  is  only 
after  the  victory  is  achieved  that  the  wounded 
arc  thought  of  by  their  comrades,  who  in  scour- 
ing the  held,  find  many  a  dear  friend  whose  life 
has  paid   the   forfeit   o\'  delay. 

The  practice  too  frequent  in  our  service  of 
taking  off"  the  surgeon  of  a  regiment  with  a 
wounded  officer,  and  leaving  the  remaining  eight 
hundred  or  one  thousand  men  exposed  to  fire 
without  surgical  aid.  is  an  abuse  of  authority 
which  cannot  he  too  severely  denounced  ;  and 
any  officer  should  be  severely  censured  who,  from 
selfish  motives,  would  allow  his  command  to  he 
thus  exposed.  Another  act  for  censure,  which 
should  render  a  surgeon  liable  to  court-martial 
for  dereliction  of  duty,  is  in  so  \';n  forgetting  his 
position  a-  n>  s/ssume  the  offensive,  and  enter  pell 
niell    into    the    fight.      The    temptation    i<    strong. 


144  DUTIKS    HI'    SI  K<;K<>N     <  •  N     liAlil.l     llKI.n. 

bul  among  the  ftrst  lessons  "I"  :i  military  sm ■_ 
U  that  of  self-restraint,  and  rigid  attention  to 
those  duties  which  are  connected  with  lii>  posi* 
tion.  His  duties  lie  with  the  wounded,  and  no4 
in  the  charge;  the  comfort,  if  n«>t  the  lives  of 
many  arc  in  his  keeping,  and  all  unnecessary 
exposure  which  be  voluntarily  incurs  can  but  be 
detrimental  t<>  the  service. 

When  our  troops  remain  in  possession  of  the 
field,  the  enemy  having  fallen  back,  the  surgeons 
should  proceed  to  the  front  of  the  line,  with  all 
possible  means  of  transportation,  t<>  collect  the 
wounded;  and  n-  most  frequently  night  bat 
in  before  the  enemy  has  yielded,  torches  should 
nrricd  by  the  hospital  or  ambulance  corps*  to 
facilitate  this  important  and  humane  search  which 
i-  tnn  frequently  neglected. 

When  our  army  retreats  and  our  wounded  have 
i«>  be  left,  soma  of  our  surgeons  should  be  left 
in  attendance,  and  supplied  with  sufficient  dress- 
ings, as  no  dependence  should  be  placed  upon 
the  medical  stores  of  the  enemy,  which  may  be 
exhausted  <»r  of  an  inferior  quality. 


CHAPTER    V. 

Tret '  tment  of  guftshot  wounds —  What  should  be  done 
on  the  field  by  the  assistant  surgeon  in  command  of 
the  Utters — '/'/<<  treatment  at  the  field  infirmary — 
Jffow  wounds  should  be  examined — Tht  character 
of  gunshot  wounds — Orifices  of  entrance  and  exit — 
Primary  fa  morrhage — Qfatural  ha  matosis — Tourni- 
quets  but  seldom  required  in  surgery — Jlmr  hemor- 
rhage controlled — Examination  of  wound  for  foreign 
bodies  should  only  be  done  inter,  but  that  thoroughly 
a  ad  as  soon  as  possible  after  the  accident — The,  his- 
tory of  the  case  important — Lodging  foreign  bodies 
always  give  trouble,  even  years  afh  r  injury — Gunshot 
wounds  do  not  require  dilation — Necessity  of  ex- 
amining the  pulsation*  of  tJtc  main  artery  below 
ihi  wound  for  suspected  injury  —  Ligation,  of  the, 
open  mouths  of  the  artery  the  rule  of  practice — 
Water-dressing  tfa  only  rationed  treatment  of  gun- 
shot wounds;  its  advantages  over  all  other  applica- 
tions— Secondary  hemorrhage,  how  treated — General 
or  constitutional  treatment  of  gunshot  wounds. 

As  a  soldier  tails  or  is  wounded  in  battle,  lie 
is  nt  once  approached  by  the  assistanl  surgeon, 
who    looks    at    liis    wounds,    applies    the    hast} 


146  Kll.il>    BURGRRY    WITH    TllK    TRANSPORTS. 

sing  which  they  reqiiire,  then  piecing  him 
comfortably  on  the  Litter,  attends  to  his  trans- 
portation. 1I«'  can  d<>  us  iiukIi  for  the  wounded 
in  this  way  as  if  he  were  actively  engaged  in 
operating.  Should  liis  injury  permit  him  to 
walk,  a  compress  ami  bandage  is  placed  upon  liis 
wounds,  it'  they  be  severe,  and  he  is  directed  to 
the  field  infirmary.  In  those  with  fractured 
limbs,  a  rapid  glance,  quick  intelligence,  and  an 
inventive  turn,  at  once  tells  the  Burgeon  what 
'-  required,  and  suggests  the  means  of  effecting 
it.  Witli  a  sword-blade,  a  ramrod,  or  a  bayonet, 
with  a  handkerchief  or  Btrip  <>f  cloth,  a  fracture 
apparatus  is  at  once  improvised,  and  the  thanks 
el'  tin-  wounded,  pow  in  comparative  comfort, 
are  freely  bestowed  during  his  transportation  to 
the  infirmary  or  gene  nil  hospital.  If  he  has  a 
mangled  limb,  which  hangs  by  a  very  small  por- 

ti i'  the   Bofl   parts,  the   separation  should  be 

at  once  effected  by  separating  the  dangling  parts 
in  the  mangled  tissues.  Should  he  be  suffering 
much    pain,    which    is    not     usually     the    case,   the 

eon  gives  him  a  powder  of  morphine,  with 
wbicn  his  pockets  are  well  stored,  and  at  once 
transports  him  to  the  infirmary,  where  the  proper 
amputation  is  performed.  If  the  wound  be  an 
abdominal  one,  with  protrusion  of  the  intestines, 


FIELD    SUROERY    WITn    THE    TRANSPORTS.  14" 

lie  sees  whether  the  bowel  is  injured  or  not.  If 
not  injured,  returns  it.  carefully  within  the  abdo- 
men, and  gives  a  Large  (\o<v  of  morphine  to  en- 
sure quiet.  Should  the  intestine  be  cut  by  tbe 
ball,  lie  warns  the  carriers  and  assistants  from 
interfering  until  the  wounded  man  be  carefully 
transported  to  the  infirmary.  In  ease  of  punc- 
tured cheat  wounds,  with  internal  hemorrhage, 
coughing  of  bloody  sputa,  and  great  oppression 
in  the  breathing,  the  treatment,  to  be  ultimately 
sueeessful,  must  commence  at  once.  The  sur- 
geon, in  placing  the  wounded  man  in  the  litter, 
will,  if  the  symptoms  be  urgent,  open  a  vein 
in  his  arm  to  save  him  from  immediate  death. 
To  this  timclv  bleeding,  on  the  very  spot  where 
the  accident  has  occurred,  and  not  wait  until 
transported  to  a  more  convenient  place,  the  life 
of  the  soldier  often  depends.  Those  wounded 
in  the  head,  if  insensible,  require  very  careful 
transportation;  they  should  be  as  little  disturbed 
as  possible.  Chest  wounds,  head  wounds,  and 
fractured  legs  give  the  most  trouble,  as  they  re- 
quire the  greatest  care  in  conveying  them  safely 
to  the  designated  places  for  surgical  treatment. 
It  is  seen  from  this  rapid  sketch,  that  the 
surgeon  who  follows  the  troops  into  action  has 
nothing    to   do   with    amputations,  resections,   ex- 


148       irai  srucKiM  with  tiik  mwwm 

tracting  foreign  bodies,  etc.;  those  form  n<>  por- 
t i < > 1 1  of  his  duties.  His  province  is  solely  to 
prepare  the  wonnded  for  successful  transport* 
lion,  and  beyond  tliis  In-  should  not  intrude 
hi-  attentions.  The  grea(  perfection  <>i  rifled 
weapens  have  their  influence  upon  the  duties  of 
the  field  Burgeon)  as  the  rapid  and  frequent 
changes  of  the  battle  held  tin-eaten  to  control, 
within  very  narrow  limits,  field  surgery  proper, 
ami  necessitate  very  hasty  dressing. 

An  eminent  military  surgeon — Mr.  Guthrie — 
states  that  bandages,  applied  on  the  field  of 
battle,  are,  in  general,  so  many  things  feasted, 
as  they  become  dirty  and  still',  and  are  usually 
cut  away  and  destroyed  without  having  heen 
really  useful.  There  is  much  truth  in  this 
statement.  Much  of  the  hasty  dressing  by  the 
transport  surgeon  can  very  well  he  dispensed 
with.  As  he  has  neither  the  time,  nor  is  it  his 
duty  to  examine  carefully  the  wounds,  nio-t  of 
tin'    wounded    mig&1     he    sent    directly    on    to    the 

field  infirmary  without   dressing.     The  dressings, 

when    removed    at     the    Held    infirmary,  are    so 

soiled  that  they  are  thrown  away.  Time,  which 
is   so   valuable,   and   also   material,   which    is   never 

in   excess,  hui   most  frequently  deficient,  can  he 

Saved     by     adopting    this   course.       Only     in    cases 


Fir.i.rt  sri;<!KUY  PKorn:.  I  !'.» 

of  active  hemorrhage  would  it  be  necessary  to 
apply  compresses  and  the  roller  bandage,  or 
what  is  more  rarely  required,  the  tourniquet. 

Should  the  soldier  have  a  targe  artery  wounded, 
and  the  hemorrhage  he  excessive,  which  is  but 
seldom  the  case,  the  surgeon  should  instruct  the 
orderly  who  superintends  his  transportation,  how 
to  make  judicious  finger  pressure.  This  is  much 
better  than  the  tourniquet,  producing  much  less 
engorgement  of  the  injured  tissues. 

Field  surgery,  properly  speaking,  commences  at  the 
1nl<l  infirmary*  Here  all  wounds  are  thoroughly 
examined,  and  an  accurate  diagnosis  established. 
The  wounds  are  thoroughly  cleansed;  all  foreign 
bodies  which  can  he.  are  removed,  and  the  first 
dressing  made.  If  the  wounds  are  trivial,  they 
are  dressed  and  the  men  sent  to  rejoin  their 
companies. 

When  the  wounds  are  quite  recent,  before  the 
tissues  become  engorged,  there  is  a  temporary 
ul'M'hcc  of  pain  and  a  relaxation  of  the  injured 
parts,  Which  favors  an  examination.  The  wound 
should  now  be  examined  to  its  very  bottom,  to 
detect    the    presence   of  foreign   bodies,  whether 

they  he  halls,  wadding,  portions  of  clothing,  de- 
tached spicules  of  bond)  etc.     For  tkk  pwrp&a    flu 

limjrr  is  ihc  /»■<>/><  r  probe,  and   is    used   on   all  oeca- 


1.".  I  EXAMINATION    OF    WOUWD8. 

sions,  with  but  rare  exceptions'.  It  is  an  intelli- 
gent instrument,  and,  appreciating  what  it  feels, 
it  will  not  onlv  discover  the  character  of  foreign 
bodies  complicating  the  canal,  but  will  avoid 
increasing  the  dangers  by  making  new  lesions 
in  the  depth  of  the  wound.  In  fresh  gunshot 
wounds,  the  apertures  which  the  balls  now  used 
IB  warfare  make,  are  large  enough  to  admit  the 
linger  when  introduced  with  Cftre.  \"erv  rarely 
is  it  necessary  to  dilate  a  wound  with  the  probe- 
pointed  bistoury,  to  assist  in  its  exploration. 
The  .silfn-  proh  is  a  dangerous  "ml  deceptive  vnMm- 
menl,  and  should  be  discarded,  from  the  battie  Jtetok 
Its  use  on  such  occasions,  For  exploring  recent 
wounds,  marks  the  novice. 

Halls  are  readily  detected  in  a  fresh  wound,  by 
placing  the  patient  in  the  position  in  which  he 
received  the  injury,  if  the  direction  from  which 
the  ball  came  be  known.  Portions  of  clothing 
and  wadding  are  detected  with  greater  difficulty!. 
Before,  however,  probing  the  wound  for  the  de- 
tection of  foreign  bodies,  be  quite  sure  that  the 
clothing  of  the  soldier  has  been  perforated. 
Often,  a  single  orifice  is  seen  leading  into  a  limb 
without  exit,  which  would  at  once  BUggSsI  an 
embedded  ball  ;  when  an  examination  of  the 
clothing  would   show    that   the   ball   had   driven 


EXAMINATION    OF    WOUNDS.  151 

these  into  the  wound,  without  sufficient  force  to 
transfix  them,  :m<l,  on  removing,  hastily,  the 
clothing,  the  hall  had  been  extracted  hy  this 
diverticulum  pushed  in  before  it.  This  exam- 
ination of  the  clothing  will  save  much  time  to 
the  surgeon,  and  painful,  protracted,  injurious 
probing  to  the  wounded. 

AmOng  the  wounded  Federalists  from  the  bat* 
tie  of  Manassas  in  the  general  hospital  at  Rich- 
mond, a  case  came  under  my  observation  which 
well  exemplified  the  necessity  of  observing  this 
rule.  It  was  that  of  a  German  who  had  been 
shot  in  the  head,  over  the  left  parietal  hone.  As 
the  scalp  was  wounded  and  the  bones  crushed, 
ilie  escape  of  fragments  during  the  treatment 
left  an  opening  through  which  the  pulsations  of 
the  brain  could  he  readily  discerned.  As  there 
was  no  counter-opening,  the  conclusion  was  en- 
tertained that  the  ball  had  entered  the  skull  and 
was  now  lying  embedded  in  some  portion  of  the 
brain.  The  case  was  cxhihited  as  one  of  those 
rare  instances  in  which  a  foreign  body  could  re- 
main in  contact  with  the  brain  without  produc- 
ing cerebral  disturbance.  It  was  not  until  some 
weeks  after  admission  that  his  cap  was  examined, 

when  it  was  found  indented  and  stiffened  with 
blood,  showing  that  it   had   been   pushed   into   the 


L52  I  -\.\MI\  \  TloN    OF    \V<MNl>s 

Wound  before  the  Wall.  Tlie  cap  had  been  .-light- 
ly nit  by  the  .-harp  edge  of  bone  from  tin-  pn 
ure  of  the  ball.  bu1  there  was  no  openiug  -ulli- 
cieiitly  Large  1m  permit  ;i  ball  to  pass.  An  earlier 
examination  of  the  cap  would  nave  robbed  the 
ease  <>l'  much  of  its  interest. 

When     the    shirt    or   drawers   arc    not     Torn,    no 

foreign  body  could  have  been  Lodged  in  the  flesh 
which  they  were  covering.       From  the  nature  of 

fresh  wounds,  the  examination  and  removal  of 
all  foreign  bodies  will  l»e  more  easily  accom- 
plished at  an  early  period,  and  with  less  pain 
and     danger   to    the    wounded  ;     it   should    he   done 

carefully,  thoroughly,  and  without  delay. 

A  regular  report  is  kept  of  all  the  cases  dressed 
at  the  held  infirmary,  and  a  brief  description  of 
each  ease  is  sent  on  with  the  patient  to  the  gen- 
eral hospital ;  so  thai  if  proper,  officers,  in  whose 
judgment  the  hospital  stall'  can  confide,  had  pre- 
viously examined  thoroughly  the  wound,  and  sent 
on  their  report,  no  further  examination  is  needed. 
The  pinning  a  card  to  the  coat  of  the  wounded, 
upon  which  is  written  the  history  of  the  wound, 
saves,  time,  pain  ami  trouble  at  the  regular  hos- 
pital. //'  tht  surgeon  &<  trustworthy,  his  diagnosis 
slniiihl  h,  respected,  <n<<I  /m  further  investigation  /></■- 
miital.      Many   serious   cases    can    he   protected    by 


EXAMINATION    OF    WOUNM.  1  ~^> 

adopting  this  simple  expedient.  In  many  cases, 
this  is  the  only  examination  which  the  wound 
will  need.  The  neglect  or  insufficiency  of  the 
first  examination  is  often  the  after-cause  of  the 
loss  of  a  limb  and  even  life.  .After-examinations 
heighten  irritation  and  inflammation  in  the 
wonnd,  and,  as  they  permit  air  (which  ought  to 
be  rigorously  excluded)  to  pass  to  the  bottom  of 
the  wound,  this  promotes  the  decomposition  of 
the  extravasaled  fluids  and  exudations,  induees 
suppuration  and  sloughing,  and  predisposes  to 
pyaemia,  with  its  fatal  sequelae.  Many  a  limb  and 
life  would  he  preserved,  if  the  examination  of 
gunshot  wounds  could  he  limited  to  the  hattle 
field  :  and  military  surgery  will  have  attained 
great  perfection,  when  a  thorough  diagnosis  is 
obtained  by  tins  first  examination. 

The  extent  and  nature  of  gunshot  wounds  are 
often  ascertained  at  a  glance.  Touching  a  limb 
may  lie  sufficient  to  indicate  to  the  experienced 
surgeon  the  extent  and  character  of  the  wound 
and  the  appropriate  treatment  ;  whilst  other 
wounds,  which  appear  trivial,  as  those  in  the 
neighborhood  of, joints,  may  require  all  the  skill 
and  scrutiny  of  the  most  experienced  to  obtain 
a  satisfactory  diagnosis.  >u>  haste  shonld  he 
permitted    in    this   examination,    to    the    injury  of 


l.".|  imKSSINCI    OF    WOUNDS    nN    TIIK    FIKLH. 

th<-  wounded,  through  carelessness  "t'  diagnosis. 
Should  large  arteritis  be  injured,  they  should  be 
ligated  always  in  situ  above  and  In-low  the  point 
injured,  and  fer  this  purpose  the  wound  must  be 
enlarged. 

As  a  general  rale,  torn  tissues  will  reunite, 
whilst  bruised,  crushed  tissues  slough.  All 
wounds  in  which  a  probability  exists  of  union 
by  the  first  intention,  should  be  nicely  adjusted 
by  adhesive  plaster.  The  great  inconvenience 
of  the  ordinary  diachylon  plaster,  which  requires 
heat  to  make  it  adhere,  must  exclude  it  from 
field  service.  The  Husband's,  or  isinglass  plas- 
ter, is  much  more  easily  applied,  requires  no  heat, 
a  little  moisture  being  all  that  is  needed,  is  not 
injured  by  hot  weather,  and  when  closing  a 
wound,  gives  as  much  support  as  the  diachylon. 
It  also  excludes,  completely,  the  air,  with  its 
injurious  influences,  which  is  not  its  least  ad- 
vantage. Diachylon  piaster  is  rather  required 
for  hospital  practice,  where  it  is  used  to  dress 
suppurating    wounds,    from    which    the    continued 

discharge  of  pus  would  loosen  strips  of  isinglass 
plaster. 

Should  a  limb  be  so  injured  that  joints  are 
largely  opened  into,  main  blood-vessels  and  nerves 
torn  through,  soft  parts  extensively  lacerated,  or 


NERVOUS    SHOCK.  165 

a  limli  Hayed,  then  amputation  should  follow  im- 
mediately the  condemnation  of  the  limit:  field 
surgery  here  proves  itself  the  only  successful  sur- 
gery, ;is  all  statistics  dearly  show.  If  the  limh 
is  simply  fractured,  even  if  comminuted,  without 
injury  to  the  main  blood-vessels  and  nerves,  and 
without  complications  with  joint  injuries,  they 
should  he  considered  simple  fractures,  and  dressed 
as  such  at  the  tield  infirmary.  If,  in  eonneetion 
with  a  condemned  limh,  other  mortal  injuries 
exist,  the  impropriety  of  performing  the  amputa- 
tion is  clearly  seen.  When  joints  are  crushed, 
or  the  heads  of  hones  perforated,  resections  are 
urgently  demanded,  and  should  he  performed  he- 
fore  reaction   takes  place. 

It  is,  of  course,  understood  that,  although 
wounds  might  he  examined,  foreign  bodies  re- 
moved, and  the  wound,  if  simple,  dressed  whilst 
a  soldier  is  suffering  under  shock,  no  serious 
Operation,  which  would  still  furlher  depress  the 
nervous  powers  or  cause  a  further  loss  of  hlood, 
should  be  performed  until  extreme  depletion 
suhsides.  Although  the  nervous  shock  accom- 
panies the  most  serious  wounds,  it  may  often  he 
met  with  in  the  most  trivial  injuries.  It  is  re- 
cognized by  the  sutferer  becoming  cold,  taint 
and   pale,   with    the  surface   hedewed    with    a  cold 


MKVers   SHOCK. 

sweat;  the  pulaM  i>  small  and  flickering;  there 
is  anxiety,  mental  depression,  with,  at  times,  in- 
coherence of  speech.  Often,  this  shock  is  rery 
transient  when  accompanying  simple  wounds. 
A  drink  of  water  and  a  few  Bneonraging  words 
may  be  sufficient  to  dispel  it.  When  it  persists, 
even  where  the  injury  appears  trivial,  it  fane- 
bodes  trouble;  and  a  more  careful  examination 
may  detect  a  fatal  injury.  It  is  the  duration. 
more  than  the  degree  of  shock,  which  marks 
the  Mrioofi  character  of  the  wound;  and  when 
this  oenstitutiona]  alarm  persists,  there  it  greart 
tear  that  hidden  mischief  is  lurking,  and  the 
surgeon  should  be  very  guarded  in  his  opinion 
of   the  ease.      Keeping    the    patient   warm,    ill    the 

recumbent  posture,  with  blankets  and  hot  bot- 
tle-, administering  wine,  brandy,  ammonia,  harts* 
horn  to  the  nostrils,  frictions  and  eataplasms  to 
the  extremities,  is  the  course  pursued  to  restore 
nervous  energy. 

In  all  painful  operations,  chloroform  should 
be  freely  administered  l<>  produce  the  desired 
anaesthesia.  Like  nil  valuable  medicinal  agents, 
whicli  when  taken  in  overdoses  are  poisons,  it 
can  remove  suffering  or  destroy  life  according  to 
dminislration.  The  dangers  can  he  avoided 
l>\     never    pushing     its     inhalation     to     stertorous 


REMOVAL    TO    TTIK    GENERAL    HOSPITAL.  157 

breathing,  but  fey  rtopping  its  xmrt  as  soon  as 
insensibility  is  attained.  The  recent  Crimean 
and  Italian  wars,  in  recording  the  advantages 
of  chloroform  in  field  surgery,  show  it  to  be  now 
one  of  the  indis|tensal»les  for  successful  practice. 
It  saves  the  lives  o\'  many  wounded,  who  would 
perish  from  the  shock  of  a  second  operation  ; 
and  also  many  who  would  have  heen  considered 
as  without  the  pale  of  surgical  art,  can  now, 
thanks  to  this  invaluable  remedy,  he  benefitted 
by  surgery. 

In  our  country,  railroads  traverse  everv  por- 
tion of  the  states,  and  as  battles  usually  occur 
in  the  immediate  neighborhood  of  thoroughfares 
between  large  cities,  it  is  not  improbable  that 
they  will  be  found  in  the  immediate  vicinity  of 
battle  fields.  If  such  be  the  case,  a  suflicient 
number  of  cars  should  be  kept  in  readme*  for 
the  use  ot  the  wounded.  Transport  wagons  are 
in  constant  communication  with  the  tield  infir- 
maries. As  the  wounded  are  attended  to,  thev 
should  not  be  allowed  to  accumulate  around  the 
infirmary,  but  be  scut  oft'  at  once  to  the  nearest 
railroad  station,  from  whence  ihey  will  be  dis- 
tributed in  the  towns  nearest  to  the  scene  of 
action.  General  hospitals  should  have  been  pre- 
viously  prepared    in     these     localities    for    the    iv- 


IJS  REMOVAL    TO    THE    GENERAL    HOSPITAL. 

caption  of  the  wounded:  and  here  the  regular 
treatment  commenc 

1  > u r i 1 1 u*  : i  general  engagement,  each  field  infir- 
mary should  be  in  constant  communication  with 
t!ii-  general  temporary  hospital  which  Hie  med- 
ical   director     has     located,    and     as     soon     as    the. 

wounded  are  examined  and  dressed;,  they  should 

be  sent  without  delay  to  this  point  This  allows 
the  field  infirmary  to  change  its  position,  and 
t<>  follow  the  division  to  which  it  is  attached. 
W  this  transportation  of  the  wounded  be  property 

attended  to,  no  wounded  should  he  left  by  night 
at   the   field    in  tinnaries. 

Another  advantage  in  not  allowing  an  accu- 
mulation of  wounded  at  field  infirmaries,  is  in 
avoiding  confusion,  should  there  he  a  reverse  of 
our  arms,  and  an  advance  of  the  enemy  upon 
the  site  of  our  field  hospitals.  Should  the  ambu- 
lance wagons  not  he  sufficient  to  transport  the 
wounded.  wagons,  carts,  carriages,  and,  in  fact, 
every    species    of   vehicle,    should    be   impressed 

from  the  neighboring  inhabitants,  so  as  to  insure 
for   the    wounded   a     place   of    safety   and   comfort. 

If  i;   he  convenient   for  the   wounded  to  reach 

the  genera]  hospital  within  twenty-four  hours 
from  tie-  reception  Of  their  injuries,  many  serious 
Cases   i'^r   operation.  Mich   as   the    resections,  might 


DKKSSINCJ    OF    WOUNDS    ON    THE    FIELD.  159 

well  l>e  deferred  from  the  field  infirmaries  until 
the  wounded  have  arrived  at  the  station  where 
that  quiet  and  rest,  with  medical  comforts,  which 
arc  so  necessary  for  a  successful  resulf,  can  he 
obtained,  "When  the  wounded  are  brought  to 
the  field  infirmary,  they  are  not  attended  to  in 
the  order  in  which  they  arrive.  Those  most 
seriously  injured  always  receive  the  earliest  at- 
tention, officers  and  soldiers  awaiting  their  turn. 
If  the  trivial  accidents  had  heen  dressed  upon 
the  field,  they  could  pass  directly  on  toward  the 
railroad  or  the  general  hospital,  without  stop- 
ping at  the  field  infirmary. 

The  common  dressings  which  all  wounds  re- 
ceive is  a  wet  cloth,  covered  with  a  piece  of 
oiled  silk  or  waxed  cloth,  and  secured  with  a 
single  turn  of  the  roll  of  handage.  This  keeps 
the  wound  moist,  and  is  the  most  soothing, 
comfortable,  efficient  and  simple  dressing  which 
can  he  devised.  By  wetting  the  outer  bandage, 
the  cold  produced  by  evaporation  is  transmitted 
through  to  the  wound,  whilst  the  oiled  silk 
keeps  the  parts  moist.  When  oiled  or  india- 
iuhhei-  cloth  cannot  he  obtained,  and  no  facili- 
ties exist  for  keeping  the  wound  constantly  wet. 
whilst  the  patient  is  being  transported  to  the  gen- 
eral   hospital,  a  eloto   well    greased   with   olive  oil 


lOO  REMOVAL    To    THE    (IKNKKAl.    HOSPITAL. 

is  the  best  substitute  for  the  wot  dressings.  Many 
ragged  wounds  may  have  their  edges  pared  off 
and  then   brought   together,   with  every  prospect 

of    a    speedy    uni<»n.   provided    tin-    after-t '"''at nn'iit 

with  cold  dressings  La  judiciously  followed. 

It  is  understood  that  all  those  who  can  he 
conveniently     moved,    should     he    transported     at 

the  earliest  possible  moment  to  general  hospi- 
tals,   established    in    contiguous   towns.      Should 

there  be  no  facilities  for  this  transportation, 
then  any  house,  in  the  neighborhood  contigu- 
ous to  the  battle  held,  must  he  used  as  a  tem- 
porary hospital  for  the  treatment  of  those  se- 
riously wounded,  whose  safety  depends  upon 
absolute  opiiet,  rest  and  careful  nurs'ino,  or  tents 
can  he  pitched  for  the  temporary  aeeommoda- 
tion   of  the  wounded. 

Should  the  army  advance,  the  regimental  sur- 
geons must  follow  their  commands,  leaving  either 
an  assistant  or  an  extra  medical  attendant  for  the 
wounded,  it  being  presumed  that  a  reserve  medi- 
cal corps  had  been  attached  to  the  army  for 
extra  or  reserved  duty,  when  it  was  known  at 
headquarters  that  a  battle  was  expected.  These 
Reserve  surgeons  will  make  every  preparation  for 
ihc  comfort  and  aeeomniodation  of  the  wound- 
ed.     Should    the  army    unfortunately    meet  with 


SIKiiKOXS    LEFT    WITH    THF.    WMTWnKTV  ICil 

a  reverse,  all  available  means  of  transportation 
must  lie  pressed  into  the  service  for  the  re- 
moval of  the  wounded  to  the  roar,  and  they  must 
be  sent  off  as  Bpeedily  as  possible.  If  tins  had 
been  attended  to  from  the  commencement  of  the 
engagement,  there  would  be  fewer  to  move  later 
in  the  day,  when  a  retreat  was  compulsory.  No 
wounded  soldier,  whose  injuries  are  so  slight 
that  he  can  walk,  should  ever  he  carried,  as  he 
lakes  up  a  place  in  the  transport  wagon  which 
excludes   one    who    cannot   assist    himself. 

There  are  many  cases  of  injury  to  which  long 
transportation  would  he  certain  death.  If  the 
general  hospital  cannot  he  conveniently  reached, 
such  cases  must  be  treated  at  some  farm-house 
.contiguous  to  the  field  of  battle:  and  if  troops 
are  compelled  to  retreat,  humanity  dictates  that 
the  severely  wounded  should  always  be  left  to 
the  enemy,  with  a  sufficient  number  of  competent 
surgeons  to  look  after  their  wants.  AVhcn  left 
without  surgeons,  they  are  always  neglected,  and 
many  lives  may  be  sacrificed  for  want  of  that 
immediate  attention  which  the  enemy's  surge, his 
musl  first  give  to  their  own  wounded,  and  which 
precious  time  can  never  be  recovered.  This 
becomes  especially  urgent  where  the  nations  at 
war  speak  different  Languages.  The  rule  uow 
1  1 


162  SURGEONS    LEFT    WITH    Til!.    \V(U   NHKH. 

recognized  in  civilised  warfare  is,  always  to  Leave 
competenl  Burgeons  witb  the  wounded  who  arc 
left  to  be  cared  for  by  the  enemy. 

The  following  excellenl  advice  is  offered  by 
Dr.  Millengen  to  Burgeons  who  may  be  placed 
in  Buch  trying  conditions:  "  When  surgeons  are 
thus  placed  on  duly  with  an  euemy,  they  must 
bear  in  mind  thai  the  welfare  of  our  wounded 
will,  in  a  great  degree,  depend  upon  the  pro- 
priety of  their  conduct.  No  irritation  <>i'  mind 
from  disappointment,  no  national  feeling,  should 
induct.'  them  t<>  enter  into  unpleasant  discussions. 
They  should  especially  endeavor  to  cultivate  a 
friendly  intercourse  with  their  medical  brethren, 
carefully  avoiding  altercations  on  professional 
points,  in  which  most  probably  they  may  differ. 
A  deviation  from  this  prudential  course  lias 
often  proved  the  source  of  jealousies  and  ani- 
mosities, from  which  the  wounded  ultimately 
suffered.  When  the  enemy's  wounded  are  nu- 
merous, and  their  surgeons  are  not  in  siillicient 
numbers   to  attend   to   them,  we  should  invariahly 

volunteer  our  assistance,  should  our  duties  afford 

us  leisure.  Such  a  line  of  conduct  is  ever  ap- 
preciated, and  cannot  fail  to  lead  to  ultimate 
reciprocal   advantages  and  good  feeling."* 


\        ,    imbalance,  in  Costello't  Cyclopoedia  of  Practical  Surgery. 


APPEARANCE    OF    GUNSHOT    WOUNDS.  K>3 

Al'PEARANCE    OF     GUNSHOT     WOUNDS. — We    have 

already  stated  that  the  more  perfect  and  de- 
structive arms  now  in  use  in  modern  warfare, 
and  the  variety,  form  and  size  of  missiles,  have 
modified  materially  the  symptoms  and  march  of 
gunshot  wounds.  The  conical  shot,  with  its  ex- 
cessive momentum,  transfixes  the  tissues  with 
great  rapidity,  and  when  only  soft  parts  are  in- 
volved, the  crushing  and  bruising  is  by  no  means 
so  extensive  as  with  round  ball.  The  entrance 
made  by  a  conical  hall  in  the  skin  is  oval,  and 
sometimes  even  linear,  as  if  made  by  the  point 
of  a  sabre.  Usually,  they  pass  directly  through 
the  soft  parts,  rarely  burying  themselves,  and, 
when  not  impeded  in  their  transit,  there  is  but 
little  difference  between  the  two  orifices  of  en- 
trance and  exit.  When  the  conical  ball,  enter- 
ing point  foremost,  and  meeting  some  resistance 
in  its  course  through  the  tissues,  is  either  changed 
in  form  or  is  turned  upon  its  side,  the. orifice  of 
exit  is  found  very  large,  and  irregularly  torn, 
with   the    surrounding   tissues    much    bruised. 

Round  balls  usually  give  an  irregularly  rounded 
entrance,  surrounded  by  discolored,  depressed  tis- 
sues: these  having  been  evidently  mashed  or 
crushed  by  the  ball  prior  to  its  entrance.  The 
ti.-sues  around  the  orifice  of  cxil   are  usually  more 


164  Al'PEARAM'K    SI    Cl'NSlInT    Worses. 

or  less  protruding  and  lacerated.  These  two 
orifices  are,  however,  modified  in  appearance  by 
s<>  many  circumstance* — the  form,  size,  velocity 
and  Dumber  of  the  missiles;  changes  in  the  mis- 
sile after  its  entrance  into  the  body  and  prior  to 
its  escape;  the  distance  of  the  wounded  person, 
his  position,  bis  clothing,  foreign  bodies  which 
may  have  been  about  his  person,  and  driven 
before  the  hall,  etc. — that  in  some  cast's,  without 
the  history  of  the  accident  from  the  patient  or 
Obese  who  saw  the  occurence,  it  would  be  diffi- 
cult to  determine  which  opening  was  first  made. 
The  effects  produced  hv  the  action  o['  the  hall 
upon  the  two  orifices  can  be  easily  understood 
when  it  is  remembered  that,  in  entering,  the 
tissues,  which  arc  being  perforated,  are  support- 
ed by  the  entire  thickness  of  the  limh,  so  that 
often  the  hall  carries  before  it  a  piece  of  flesh 
which  it  has  cut  out  as  hv  a  die,  and  hence  the 
more  or  less  rounded  appearance  of  this  open- 
ing. After  traversing  the  limh,  in  making  its 
exit,  the  tissues  through  which  it  is  now  pushing 
have  no  support,  they  are  stretched  inordinately 
before  they  are  torn,  hence  the  flap-like  lacera- 
tions of  this  exit,  with  sometimes  nothing  more 
than  a  rent  or  split  in  the  skin.  All  who  are 
familiar    with    the    driving    of    a    nail    through  a 


APPEARANCE    OF    GUNSHOT    WOUNDS.  166 

beard,  or  firing  at  tlic  sumo  with  a  pistol,  will 
see  a  rough  working  of  this  principle.  These 
peculiarities  are  said  to  be  so  stamped  upon  the 
clothing,  that  often,  by  an  examination  of  them 
alone,  a  diagnosis  can  be  established. 

It  is  often  of  con  sequence  to  determine  the 
character  of  these  apertures,  so  as  to  distin- 
guish between  a  traversed  hall,  with  its  two 
orifices,  or  two  halls  embedded.  At  the  same 
time,  it  mnst  not  he  forgotten  that  one  hall  may 
make  several  openings,  by  the  hall  being  divided 
in  the  limb  upon  a  sharp  crest  of  bone.  Such 
eases  are  not  unusual  where  the  round  musket 
hall  strikes.  A  half  of  the  ball  may  pass  out, 
a  portion  remaining  behind.  A  single  hall,  by 
splitting  in  this  way  against  some  obstacle  in  the 
llesh.  has  been  known  to  break  into  six  pieces. 
each  in  exit  making  a  corresponding  wound. 

Conical  balls  show  much  less  deviation  than 
round  halls.  They  usually  take  a  straight  course, 
ploughing  through  all  opposing  structures:  noth- 
ing resists  the  penetrating  force  of  these  projec- 
tiles. They  seldom  follow  the  contour  of  bones, 
as  the  round  often  do.  but  at  once  crush  them; 
their  double  weight  and  increased  velocity  mak- 
ing many  more  fractures  than  the  round  hall  of 
former  wars. 


lilt",  \i;.\mi:   Of   i.i  CT8H0X    WOl  NDS. 

In  spite  "t'  1 1  j  *  -  rapid  passage  of  evea  conical 
balls,  some  of  the  tissues,  through  their  toughness 
ami  elasticity,  escape  direcl  injury  from  them. 
Arteries  come  under  this  head.  Owing  to  their 
peculiar  structure,  cylindrical  form,  and  loose 
connections,  Lying  in  a  bed  <>f  very  loose,  cellu- 
lar tissue,  which  permits  of  considerable  move- 
ment, they  often  escape  transfixion,  when  their 
positiou  lies  evidently  in  the  direct  course  of 
the  ball.  In  1859,  during  the  Italian  difficulties, 
and  after  the  battles  of  Magenta  and  Soiferino,  I 
saw  several  of  the  wounded  in  the  hospitals  at 
Milan,  who  had  rec<  ived  such  injuries  aboul 
the  rool  of  the  neck,  where  balls  had  traversed 
in  some  cases  antero-posteriorily,  in  others  later- 
ally, going  deeply  through  the  soft  parts,  yef 
picking  their  way,  as  it  were,  with  such  care  as 
to  avoid  the  great  vessels  among  which  the  mis- 
sile had  channeled  its  course.  So  great  is  this 
power  of  avoiding  perforation  in  the  huge  arte* 
,  thai  carely  does  death  take  place  on  the 
battle  field  from  division  of  the  huge  vessels  ^i' 
the  extremities  by  bullets. 

When  a  ball  strikes  a  limb  fairly,  at  right 
angles,  it  produces  the  least  injury  to  the  tissue 
which  it  traverses;  it  forms  a  simple  canal, 
which    may    heal    with    vcvy    little    suppuration    or 


HEMORRHAOK    IN    CitfNSHOT    WOUNDS.  1<>7 

sloughing ;    but    when    it    strikes    at    an    angle, 

particularly  when  the  ball  lias  lost  a  part  of  ils 
momentum,  it  ploughs  up  the  tissues  frightfully, 
and  extensive  destruction  follows. 

Although  numerous  cases  are  met  with  in 
which  gunshot  wounds  have  healed  by  the  first 
intention,  the  surgeon  must  not  look  for  such  a 
happy  result.  With  hut  rare  exceptions,  suppu- 
ration w  the  rule,  and  he  must  he  prepared  to 
control  its  action,  and  the  excessive  reaction 
which,  in  most  cases,  would  accompany  it. 

A  certain  amount  of  hemorrhage  always  ac- 
companies gunshot  wounds;  hut,  owing  to  the 
irregularity  and  the  asperities  of  the  sides  of 
the  wound  favoring  the  clotting  of  blood,  we 
usually  find  that  the  external  flow  soon  ceases, 
whilst  internal  hemorrhage,  to  a  limited  extent, 
extravasatcs  into  the  surrounding  tissues.  When 
the  divided  blood-yessels  are  so  closed  that  the 
blood-cells  can  no  longer  escape,  serous  oozing 
still  goes  on  infiltrating  the  tissues.  These  are 
the  causes  of  the  rapid  swelling  which  follows 
gunshot  wounds.  Those  arteries  which  are  di- 
vided by  a  ball  in  rapid  motion  will  bleed  more 
than  those  injured  by  a  slow  or  spent   ball. 

The  pain  which  accompanies  the  reception 
of  gun-dint    injuries   is   often    so   trivial,   thai    the 


HW  IS  \  i  i  i:  \i.    \i>\  \vr  \<.i  S   it   siimck. 

attention  of  the  wounded  is  only  called  bo  the 
fact  by  blood  streaming  down  his  legs.  The 
majority  liken  the  striking  of  a  ball  to  a  smart 
blow  willi  a  sopple  walking-cane,  wnilsl  with  a 
few  the  pain  is  very  Bevere,  and  simulates  the 
feeling  which  would  be  produced  by  running  a 
red-ho1  wire  through  the  flesh.  McLeod  men- 
tions the  case  of  an  officer  who  had  both  of  his 
lega  carried  away,  and  wlm  only  became  aware 
of  the  injury  which  he  had  received  when  he 
attempted  to  rise. 

It  appears  thai  every  gunshot  wound  is  ac- 
companied by  a  certain  anionnt  <>\'  shock,  or 
a  partial  paralysis  of  sensation,  which  is  nature's 
preparation,  permitting  a  thorough  examination, 
with  little  or  ho  pain.  The  unusual  quiel  of 
a  hospital  the  nighi  following  a  battle  has  been 
repeatedly  noticed,  and  is  accounted  for  by  this 

DervOUS   shock.      When    this    condition    passes   off, 

then    reaction    brings    with    it     much    suffering. 

In  this  nervOUfl  shock,  with  the  suspension  of 
activity  in  the  circulatory  function,  lies  the  safety 
of  many  a  wounded  soldier.  Its  influence  is  im- 
mediately felt  in  the  injured  tissues,  and  the  in- 
filtration and  engorgement  of  these  are  prevented. 
When  nervous  depression  exists,  hut  little  Mood 
escapes  from  the  injured   vessels,  and  as  there  is 


AVOID    HASTY    DRESSINGS.  169 

no  force   from   behind,  owing  to  the  diminished 

action  of  the  heart,  to  drive  on  and  keep  in  mo- 
tion this  blood,  its  dotting  is  favored.  When 
reaction  ensues,  the  ciot  is  already  so  firmly 
established  that  it  cannot  be  displaced;  the  in- 
jured vessels  remain  thoroughly  and  permanently 
plugged  up,  and  the  dangers  from  immediate 
hemorrhage  arc  prevented.  Shock  ma}*  accom- 
pany a  very  slight  injury,  and  may  exhibit  itself 
in  the  most  courageous  and  intelligent,  so  thai  it 
cannot  always  Ik'  attributed  to  alarm.  On  the 
oilier  hand,  a  very  severe  wound  may  be  unac- 
companied by  any  perceptible  agitation. 

As  the  wounded  soldier  is  always  clamorous 
of  having  his  injuries  attended  to  as  early  as  pos- 
sible, and  as  experience  teaches  that  all  wounds, 
and  above  all  others,  gunshot  wounds,  are  beuc- 
titrd  by  immediate  dressing,  they  should  be  at- 
tended to  mi  the  field  of  battle;  then  they  give 
Lata  trouble  to  the  surgeon,  less  pain  to  the  sol- 
dier, and  much  better  iinal  results  in  treatment. 
All  hasty  dressings  or  examinations  are  to  be 
deprecated,  and  a  methodical  course  pursued. 
The  indications  of  treatment,  in  all  gunshot 
wounds,  arc,  1st.  To  control  hemorrhage;  2d.  To 
cleanse  the  wound  by  removing  all  foreign  bodies. 
and,  -"id.  To  apply  BUcli  dressings  and  pursue  such 
L5 


IT"1  ARREST    OF    HEMORRHAGE. 

a  rational   course  of  treatment,  as  will  establish 
rapid  cicatrisation. 

Hemorrhage,  which  produce*  such  terror  in 
tin'  bystanders  and  anxiety  iii  the  patient,  should 
never  unnerve  the  surgeon,  who  requires  all  <>f 
self-possession  ami  Bnrgical  tad  to  cope  suc- 
cessfully with  this  ebbing  away  of  life.  Fortun- 
ately, in  gunshot  wounds,  serious  hemorrhage  is 
Ot'  rare  occurrence;  and  when  the  largest  arteries 
are  injured,  as  a  rule  they  either  cease  bleedirig 
Spontaneously,  or  the  patient  dies  so  rapidly  that 
art  is  of  little  avail.  It'  the  case  is  not  injuriously 
interfered  with,  the  natural  hemostatics  will  often 
control  the  bleeding.  The  ragged  character  of 
the  wound,  and  ilie  nervous  Bhock  accompanying 
the  injury,  or  brought  <>n  by  the  loss  of  blood, 
r<  acting  upon  the  circulatory  organs,  so  diminish 
the  heart's  impulse,  and  drives  so  little  blood  to 
the  extremities,  as  to  favor  a  stagnation  of  Mood 
in  the  wound.  The  formation  of  a  clot  plugs 
Up  the  orilice  in  a  bleeding  vessel,  and  stops  any 
Further  loss  of  blood. 

This  sp&ntaneous  arrest  of  hemorrhage  is  ustiaUy 
permanent;  and,  if  the  ordinary  prophylactic 
course  is  pursued,  of  absolute  rest  and  quiet. 
with  the  limb  elevated  and  bandaged,  no  return 
shows   itself.      Should,  on    the    contrary,  meddle- 


ARREST   OF    HEMORRHAGE.  171 

some  surgery  suggest  the  use  of  a  tourniquet, 
which  cuts  off  the  circulation,  and  especially  the 
venous  return,  the  limb  soon  swells,  tissues  be- 
come engorged,  excessive  extravasation  in  the 
wound  follows,  and  a  train  is  laid  for  future  mis- 
chief. The  Held  tourniquet,  in  former  days,  was 
so  much  in  vogue  that  it  was  considered  indis- 
pensable on  the  battle  field,  and  was.  therefor.', 
carried  in  large  numbers,  to  be  applied  to  every 
limb  from  which  blood  was  trickling,  or  from 
which  hemorrhage  was  feared.  JSTow  they  are 
nearly  discarded  from  field  service,  and  recent 
experience  recommends  their  abolition  from  the 
field,  as  doing  more  harm  than  good  to  the 
wounded.  Unless  very  tightly  applied,  it  is  of 
no  service,  as  it  does  not  control  the  bleeding, 
and  if  firmly  applied  it  acts  as  a  general  ligature 
around  the  extremity,  and  can  be  used  but  for  a 
short  time  without  injury  to  the  limb. 

Kecent  writers  warn  surgeons  of  the  too  hastv 
use  of  hemostatics,  and  suggest  that  it  is  better 
for  the  wounded  to  lose  a  little  blood,  which  will 
diminish  the  heart's  propulsive  force,  than  have 
the  wounded  tissues  tilled  with  extravasated 
blood.  If  the  hemorrhage  be  free,  immediately 
after  the  receipt  of  injury,  the  best  mode  of  con- 
trolling it  would   be  the  application  of  a  ball  of 


17"_'  AKKKST    <>F    HKMORRII 

lint,  a  compress,  Of  sponge  over  tho  wound,  at- 
on  red  by  a  bandage,  which,  in  clewing  the  outer 
orifice,  favors  ihe  formation  of  a  clot.  It'  the 
hemorrhage  is  at  nil  active,  as  from  some  large 
artery,  in  addition  to  the  compress  on  the  wound, 
tli.-  entire  limb  should  be  carefully  enveloped  in 
:i  bandage,  to  some  distance  above  the  injury, 
go  that  the  pressure  made  upon  the  soft  parts 
would  diminish  the  amount  of  circulating  fluid 
in  the  !iuil>.  and  prevent  the  ingress  of  blood 
into  the  tissues.  The  hemostatic  properties  of 
tlii-  dressing  can  be  increased  by  soaking  the 
sponge,  or  compress  covering  the  wound,  with 
the  per  chloride  or  per  sulphate  of  iron,  which, 
a-  a  powerful  astringent,  when  brought  in  contact 
with  fresh  blood,  will  immediately  form  a  clot. 
The  injection  of  a  solution  of  the  per  chloride 
of  iron  into  the  wound,  not  asing  force  enough 
to  infiltrate  the  tissues,  is  an  excellent  method 
of  establishing  a  solid  dot  up  to  the  very  bleed- 
ing mouth  of  the  injured  vessel.  A  lump  of  ice 
placed  upon  the  compress,  will  act  with  equal 
efficiency.  A  Bponge  or  compress,  tied  on  the 
bleeding  wound,  with  or  without  the  iron  styptic, 
is  all  thai  the  surgeon  superintending  the  trans- 
portation   of  the  Wounded    is    expected    to    i\n. 

Unless  the  hemorrhage  is  very   violent,  threat- 


ARREST    OF    HEMORRHAGE.  1  7^> 

on'nig  immediate  destruction  of  life,  the  tourni- 
quet is  rarely  required.  All  recent  writers  on 
military  surgery  recommend  that  field  tourniquets 
be  dispensed  with,  as  they  are  generally  a  useless, 
and  often,  when  carelessly  used,  a  dangerous  in- 
strument. The  linger  pressure  of  an  intelligent 
assistant  is  better  than  any  tourniquet  ever  made, 
and  is  a  far  preferable  means  of  controlling  ex- 
cessive hemorrhage,  which  the  compress  and 
bandage  may  tail  to  check.  The  femoral  artery, 
for  any  injury  to  its  trunk  or  large  branches, 
should  he  compressed  in  the  groin  where  it  runs 
over  the  pubic  bone  ;  the  brachial,  where  it  pul- 
sates against  the  head  of  the  humerus,  as  at  this 
point,  its  course  is  nearly  subcutaneous.  When 
the  position  of  these  main  trunks  are  shown  to 
any  intelligent  assistant,  and  he  is  made  to  recog- 
nize the  throbbing  oi'  the  artery,  he  will  have  no 
difficulty  in  keeping  the  vessel  compressed  dur- 
ing  the  transportation. 

A-  soon  as  the  wounded  arrive  at  the  tempo- 
rary resting-place,  where  the  surgeons  are  assem- 
bled, all  bandages  are  removed,  and  the  wounds 
carefully  examined.  A  glance  at  the  wound. 
when  the  clothing  bus  been  previously  examined) 
will  often  tell,  when  there  are  two  orifices  differ- 
ing in  appearance  and  in  a  direct  line  with   each 


17  1  use   tiii:   ri.NMiKR   as:   a    im: 

other,   whether    foreign    bodies   haw    lodged    Of 
not.     A>   the    patient    is    now   taint  from   !<• 
l>lood  and    from    nervous  depression,  the  wound 
not  yet  liciiiLr  painful  or  swollen,  the 
his  finger \  which  is  the  only  admissible  /'/■<•/),   <>,,  suck 

thai   the  military  surgeon   of  experient 
cognizes,  examinee  the  entire  extenl  <>t'  the  wound. 
searching  for  foreign  bodies, 

This  examination  is  made  without  fear  of  re- 
producing hemorrhage,  as  the  finger  cannot  dis- 
place ilie  clots  which  hold  firmly  to  the  open- 
lag!  in  the  resseh  Every  surgeon  haa  noticed 
haw  rudely  a  etump  might  be  ponged,  and 
what  force  it  requires  to  wipe  away  dots  which 
have  formed  over  the  face  of  a  smooth,  incised, 
open  wound.  The  adhesions  are  increased  a 
hundred-fold  by  the  irregularities  of  a  concealed 
bullet  track.  The  finger  finds  no  difficulty  in 
entering  a  hole  through  which  a  bullet  has 
passed,   if  examined,  as  every  wound  should   be, 

hei'ore    Bwelli&g    has   taken    place. 

In  examining  fresh  wounds,  a  silver  probe  will 
travel  in  (he  direction  given  bo  it  l>v  the  sur- 
geon.; and  as  most  persons  guide  the  probe  -'//- 
stood  <>f  (iliniriiKj  the -probe  to  guide  them,  the  true 
course  of  a  ball  can  only  be  determined  by  it 
with  great   difficulty.     It    is  bul    recently    that   I 


1  SE    THE    F1NOER    AS    A    PROBE.  175 

saw   a   physician    of  experience,   in   seeking   the 

course  of  a  ball  which  had  lodged  in  the  thigh, 
apparently  without  effort,  pass  the  probe  among 
the  muscles  quite  across  the  limb,  so  that,  the 
bullet  wound  being  on  the  outer  side  of  the 
thigh,  the  end  of  the  probe  could  be  felt  under 
the  skin  on  its  inner  side.  When  the  finger 
was  introduced,  it  followed  the  track  of  the  ball 
at  a  very  oblique  course  from  the  one  which 
the  probe  had  taken.  This  example  is  suincieut 
to  show  why  military  surgeons  denounce  the 
silver  probe,  and  distinguish  by  its  use  the  tyro 
in  surgical  practice.  In  those  cases  only  in 
which,  from  the  small  size  of  the  orifice,  the 
finger  cannot  .be  introduced,  is  a  bougie,  a  female 
catheter,  or  lastly,   a   silver  probe  used. 

The  wound  is  examined  from  both  sides,  with 
the  double  object  of  finding  foreign  bodies  which 
may  have  lodged,  and  seeing  the  proximity  of 
the  course  of  the  ball  to  the  main  arteries  of  the 
limb.  It  is  ;i  matter  ^l'  great  importance  to  de- 
termine the  condition  of  large  vessels,  whether 
they  be  injured  or  not.  by  examining  the  degree 
of  pulsation  which  they  possess;  as  an  injury 
would  necessitate  a  very  careful  after-treatment 
to   avoid    secondary    hemorrhage. 

In    some    cases    the   linger   introduced    into   the 


17''  r.SK    THE    KINfiKU    As     \     PR' 

opening,    after    pausing    through    the    skin    and 
cellular    tissue,    finds    no    further    \>:  This 

would  indicate  either  that  the  ball  had  been 
drawn  out  with  the  removal  of  tin-  clothing,  or 
that  tlir  deep  tissues,  muscles  and  uponcui 
have  changed  their  relations  from  the  move- 
ments  of  the  limb.  The  track  of  the  ball  can- 
not be  discovered  until  the  former  relations  of 
the  parts  be  resumed  by  placing  the  limit  in 
tin1  same  position  in  which  it  hat]  received  the 
shot,  when  the  entire  route  of  the  hall  will  he 
perceived. 

The     inexperienced,     readily     deceived     by     the 

little  resistance  met  with  in  probing  recent 
wounds,  mistaking  muscular  interstices  lor  the 
traek  of  the  ball,  make  several  Raise  passages 
in  their  search  for  the  foreign  body,  and  by 
their  isolation  or  denudation  of  the  parts,  cause 
inflammation  and  add  to  the  difficulties  of  fur- 
ther examination.  When  the  finger,  huried  in 
the  wound,  shows  that  it  is  continued  beyond 
reach,  a  bougie  or  silver  catheter  introduced 
carefully  and  without  force,  will  often  reach 
and    delect    1 1  m •    foreign    body. 

Should  hut  one  opening  exist,  and  the  cloth- 
ing of  the  soldier  covering  the  wound  be  fcoru, 
the    probability   is,    thai    foreign    bodies    oompli- 


REMOVE    ALL    FOREIGN    ROUTES.  177 

cate  1 1 10  wound.  It  must  be  remembered  that 
the  bail,  as  a  bard  body,  can  usually  be  readily 
reeognized,  but  that  portions  of  wadding  or 
clothing  may  be  easily  mistaken  for  a  clot  of 
blood  or  the  ragged  lining  of  the  wound.  This 
is  particularly  die  case  when  they  become  satu- 
rated with  the  secretions.  Forewarned  being 
forearmed,  the  surgeon,  remembering  these  diffi- 
culties, will  examine  with  special  care  for  these 
soft,  foreign  complications.  Wheta  found  they 
should  he  extracted,  as  their  presence  is  certain 
to  establish  a  high  degree  of  inflammatory  ex- 
citement, with  profuse  subsequent  suppuration. 
This  effect  was  well  shown  in  the  case  of  a 
private  of  the  "2d  Regiment  of  South  Carolina 
Volunteers,  who,  during  the  attack  on  Fort 
Sumter,  was  shot  by  the  accidental  discharge 
of  a  musket.  The  ball  entered  the  chest  at  the 
anteriof  fold  of  the  armpit,  fractured  the  clavi- 
cle, and.  after  a  course  of  nearly  six  inches,  was 
stopped  by  the  tough  skin  over  the  posterior 
portion  of  the  shoulder.  The  ball  was  readily 
detected  by  the  regimental  surgeon,  and,  by  an 
incision  through  the  skin,  was  easily  removed. 
Inflammation  <>t  a  high  grade  followed.  He 
was  sent  up  to  a  city  hospital  one  week  after 
the  accident,   when    he  was   losing  from   three  to 


I7J  III8Tni:\     OK    CASK    1M1 

four  ounces  of  pus  daily  from  the  wound.  *  Mi 
the  day  after  his  admission,  in  examining  the 
wound.  I  detected  in  the  shoulder  wound  some 
substance  resembling  a  slough,  and  upon  extract- 
ing it.  found  a  mas*  of  wadding  over  two  incites 
long  and  as  thick  as  the  finger,  which  tent-like 
mass  had  been  driven  into  the  tissues  by  the 
hall.  Kxamiiiatioii  of  his  clothing  now.  for  the 
oral  time,  showed  the  deficiency  in  .the  liuiug 
of  his  coat,  from  which  this  mass  had  been 
torn.  The  removal  of  this  irritant  diminished 
the  discharge  immediately,  so  that,  in  the  sue* 
ceeding  twenty-tour  hours,  tin-  discharge  dimin- 
ished to  .one-sixth  it>  former  quantity,  and  in 
fottr  dayi  was  hardly  sullieieiii  to  soil  the 
sing. 
The  history  of  the  case  is  of  much  import- 
ance in  examining  wounds.  Often,  the  course 
of  tlic  hall  cannot  he  discovered  without  it. 
What  surgeon,  however  e-reat  his  experience* 
seeing  a  wound  made  in  the  arm  by  a  hall, 
would  think  of  looking  in  the  opposite  thigh 
for  i t >  place  of  lodgment,  did  he  not  learn 
that  the  injury  was  received  from  above,  whilst 
mounting  a  scaling-ladder,  with  arms  raised 
above    the    patient's    head?      The    hall,    entering 

the  back  of  the  arm  near  the  elhow,  pa 


HISTORY    OF    CASE    IMPORTANT.  179 

down  the  arm  under  the  shoulder-blade,  across 
the  loin,  and.  traversing  the  buttock,  lodged 
under  the  skin  of  the  outer  part  of  the  op- 
posite  thigh,    where   it  was   found,  and  removed 

Knowing-  the  direction  from  whence  the  ball 
came,  and  the  position  in  which  the  soldier  was 
placedj  you  know  at  once  the  course  which  the 
ball  most  probably  took ;  and  .your  examinations 
in  that  direction  will  not  only  save  much  time, 
l>ut  sare  the  patient  n.  icfi  suffering  and  annoy- 
ance. Often  the  play  of  a  muscle  will  shut  off 
the  track  of  the  hall.  The  relations  of  the  soft 
p*fl£  vary  with  every  position  of  the  limb,  and 
a  passage  made  when  a  limb  was  tlexed,  could 
not  be  followed  when  the  same  limit  is  extended. 
Hence  the  necessity  of  placing  the  limb  in  the 
same  position  in  which  it  was  when  the  injury 
was  received. 

The  -"(Mind  having  been  carefully  examined 
by  the  linger  within  and  careful  manipulations 
without,  and  the  foreign  body  detected,  it  should 
be  at  once  removed.  This  rule  may  nearly  be 
considered  absolute,  as  all  military  surgeons 
place  great  weight  upon  its  accomplishment. 
'Idie  question    is   not  so  much  whether   balls  can 

remain  innocuous  in  the  flesh,  but  do  th<;j.' 
Those     who     have     had     experience     in     gunshot 


180  I.MBKDTiED    BALLS    ALWAYS    liAMiKltm  - 

wounds  iu  tlio  tit-Id,  know  how  c\ccs.-;\ -«•  is  the 
irritability  caused  by  the  presence  of  a  ball  in  a 
wound:  how  restless  ninl  irritable  the  patient  is 
until  it  is  removed;  how  profuse  the  suppura- 
tion and  prolonged  the  period  of  treatment  in 
n  which  it  has  been  left  :  and  how 
frequently  the  after-consequences  are  so  distress- 
in;r.  the  pain  so  permanent,  and  discharg 
constant,  as  to  demand  ftiture  interference  or 
make  life  a  burden.  If  such  be  the  case  with 
a  ball,  liow  much  more  urgently  is  the  extrac- 
tion of  other  foreign  bodies  indicated,  especial- 
ly fragments  ol  shell,  portions  of  clothing,  tte. 
It  is  only  by  carrying  out  this  mosl  urgent  in- 
dication in  the  ciiiniiiciicciiicnt  of  the  treatment, 
that  a  number  of  consecutive  dangers,  such  as 
pain,  inflammation,  suppuration,  gangrene,  am* 
putations,  and   even   death,   can   he  avoided. 

Balls  may,  in  time,  become  encysted,  but 
the8e  are  exceptional  cases;  and  even  when 
such  occur,  their  presence  in  after  years  may 
set  n|i  inflammation,  which  will  mat  together 
and  1  •  i  1 1 <  1  down  important  parts,  whose  useful- 
depends  upon  freedom  of  motion.  bte- 
peated  a)  may  form,  pressure  upon   hones 

may  give  rise  to  ulceration    and    a   tedious  exfo- 
liation,    blood-vessels    may    ulcerate,     nerves    be 


EMBEDDED    HALLS    ALWAYS    DANGEROUS.  181 

painfully  compressed,  and  life  rendered  misera- 
ble, it'  not  jeoparded.  Notwithstanding  what 
lias  been  written  upon  the  innoeuons  character 
of  balls  embedded  in  the  flesh,  for  every  in- 
stance in  which  halls  have  thus  remained,  with- 
out giving  trouble,  one  hundred  can  be  exhibited 
showing  the  great  danger  of  foreign  bodies  in 
the  living  tissues.  Bacon  Larrey's  experience 
showed  that,  as  a  rule,  amputations  are  eventu- 
ally necessary,  after  years  of  suffering,  in  those 
eases  in  which  balls  have  been  left  embedded  in 
boues.  These  remarks  are  equally  applicable  to 
all  foreign  bodies,  including  spicuhe. 

In  McLeod's  Surgery  of  the  Crimea,  the  re- 
port of  M.  Hutin,  chief  surgeon  of  the  Hotel 
des  Invalides,  is  given,  which  is  a  striking  com- 
mentary in  favor  of  the  removal  of  all  foreign 
bodies.  He  reports  that,  of  four  thousand  cases 
examined  by  him,  in  which  halls  had  remained 
embedded,  only  twelve  men  suffered  no  incon- 
venience; and  the  wounds  of  two  hundred  con- 
tinued to  open  and  close,  continually,  till  the 
foreign    body   was   extracted. 

When  no  doubt  exists  that  a  foreign  body 
complicates  the  wound,  the  surgeon  should  ne- 
■  •li'ct  no  precaution  to  discover  it.  As  a  general 
rule,  he  will  find  the  examination  facilitated  by 
exposing   the  entire  limb. 


1  VL'  HOW     n       I   \  lltACT    HA  II  - 

[f  the    ball   be   fell    loo*.-    in   fhe  soft  parte,  a 
bullet   forceps   can    be   1  * » : i<  1 « *   to  Beize  it  ;    and  it 
c:mi    be  extracted    without    difficulty,  provided  tfu 
hnn'l  <>/  >he  nurgvon  support   the  titnb  on 
tfu   npp  it    i<>   that  "f  which  tl-<  forceps  ia  u>- 

in,ihift,i :  otherwise,  the  ball  glides  in  front  of 
the  forceps  and  cannot  be  seised.  The  ordinary 
ballet  forceps,  simulating  the  dressing  forceps 
of  tli"  poeket  caee,  was  the  instrument  pre- 
ferred   by    Larrey,    and    is    still,    deservedly,    in 

ueral  use.  Many  changes  have  been  made  in 
these,  without  advancing  to  any  extend  the  mcr- 
:t>  of  the  instrument.  A  rery  good  bullet  for- 
oepi  is  one  terminating  with  a  sharp  prong  on 
either  blade,  at  right  angles  to  the  blades  ao 
that  when  closed  tin-  points  are  protected  by 
the  blades.  These  act  as  an  axis  upon  which 
the  ball  may  be  rolled  out  of  the  wound,  in- 
stead of  being  drawn  out  as  with  the  dressing 
forceps. 

Should  the  site  of  the  foreign  body  be  not  at 
once  evident  after  the  examination  of  the  wound, 
the  limb  should  be  carefully  manipulated  for 
some  distance  from  the  wound.  As  the  object 
of  the  examination  is  to  detect  abnormal  projec- 
tions, the  slightest  elevation  should  attract  atten- 
tion.      When    no  projection    is   visible,   pulsation 


now   TO   EXTRACT    BALLS.  183 

-will  detect  a  hard  body  at  a  great  depth  in  the 
tissues.  'Plic  hand  should  lie  run  lightly  over 
flic  surface,  as  light  pressure  would  expose  the 
indurated  spot,  the  site  of  a  hall;  when  well  de- 
fined  pressure  would  move  the  object,  push  the 
ball  back  into  its  track,  and  cause  its  disappear- 
ance. If  the  tissues  are  soft,  the  foreign  body 
can  be  seized  between  the  fingers.  If  this  be 
impossible,  palpation  over  the  region,  as  for  de- 
tecting fluctuation,  will  discover  the  hard,  resist- 
ing, circumscribed  body.  Experience  soon  makes 
perfect  in  this  kind  of  research,  and  mistake's  are 
rarely  made. 

When  a  ball  is  firmly  embedded  in  bone,  it  can 
be  removed  by  boring  into  it  with  a  gimlet,  which 
holds  it  securely,  and  permits  sufficient  force 
being  used  for  dislodging  it.  or  it  may  be  cut 
out  by  using  a  trephine.  Should  a  ball  have 
traversed  a  limb,  as  it  often  does,  and  its  escape 
be  resisted  by  the  tough,  elastic  skin  which  very 
Often  successfully  impedes  the  further  progress  of 
the  ball,  it  should  be  removed  by  making  an 
incision  over  its  position,  and  not  be  sought 
for,  and  drawn  through,  the  entire  length  of 
the   track   which    it    had   traversed. 

In    removing    subcutaneous   foreign    bodies,   do 
not  cut   down  directly  upon   them,   as  it  will   de- 


184  MOW    TO    EXTRACT    UALLs 

stroy  the  edge  of  the  knife — n  sail  accident  in 
field  practice,  where  no  conveniences  exist  for 
puttiug  instruments  in  order;  bat,  after  exposing 

a  point  of  the  foreign  body,  make  the  incision 
to  one  side,  or  pass  in  a  grooved  director  ami 
cut  outwards,  when  there  will  be  no  tear  of 
doing  harm  to  the  blade. 

Baudens,  in  noting  the  difficulty  of  extracting 

these  siihcntaneoiis  halls,  ascribes  it  to  a  layer 
of  cellular  tissue,  whieh  firmly  and  completely 
caps  the  hall.  It  is  thin  enough  to  he  diapha- 
nous ami  yet  tough  enough  to  clasp  and  hold 
firmly  the  ballet.  Gruthrie  Bpeaks  of  the  diffi- 
culties o!'  extfaetion  depending  upon  the  Bur- 
geon being  too  fearful  of  increasing  the  incision. 
I  Jails   can    he    extracted   with    the     least     pain    and 

with  great  rapidity  by  making  a  hold  incision. 
This  course  marks  the  difference  betweftn  civil 
and  military  surgeons;  half  an  inch  added  to 
the  incision  does  not  increase  its  dangers,  and 
expedites  the  extraction.  Be  quite  sure,  how- 
ever, that  you  are  cutting  upon  a  hall  and  not 
upon  some  bony  proinineuce,  which  comparison 
with  the  opposite  limb  should  warn  you  from. 
It  is  sufficient  to  mention  that  such  mistakes 
have  happened  to  military  surgeons. 

By    foreign    bodies    we    mean    halls,    pieces   of 


DILATATION    OF    WOUNDS.  185 

elothinj?,  spicuhe  of  bone  which  have  been  bro- 
ken off  and  arc  loose  in  the  wound,  and  any 
articles  about  the  person  which  may  nave  been 
driven  before  the  ball.  These  should  all  be  re- 
moved immediately  after  tlie  injury  lias  been 
received,  and  before  swelling  or  infiltration  ren- 
ders the  task  difficult.  "When  done  early,  the 
wound  will  be  found  sufficiently  large  to  allow 
ot*  easy  extraction,  without  dilating.  It  is  only 
when  this  early  attention  is  neglected,  and  the 
wound  has  closed  by  inflammatory  effusions,  that 
the  removal  is  painful  and  difficult,  requiring,  in 
some  instances,  the  use  of  the  Knife  to  enlarge 
the  passage. 

The  dilatation  of  gunshot  wounds,  which  was 
formerly  the  constant  rule  of  practice,  m  now 
altogether  rejected  from  military  surgery,  unless 
it  be  for  the  special  purpose  of  ligating  a  bleed- 
ing artery,  or  extracting  a  foreign  body,  which, 
from  changes  in  the  wound,  cannot  he  rea  lily 
extracted  without  injury  to  the  soft  parts.  This 
old  medical  dogma  was  based  neither  upon  ex- 
perience nor  observation,  and  is  now  vei-y  prop- 
erly considered  useless,  injurious  and  barbarous. 
When  a  ball  alone  complicates  a  wound,  if  it  be 
lot  readily  found,  alter  a  careful  and  intelligent 
Rearch,     rather     than     continue     the     examination 

Hi 


lv»)  l.N.l  I  HV    TO    LARGE    ARTERIES. 

from  day  to  'lav,  which  ran  only  be  prejudicial 
t<>  the  case,  from  the  irritation  and  inflam- 
mation which  will  be  excited,  it  would  save  the 
surgeoi]  much  anxiety  and  the  patient  much 
anuoyauce,  if  the  ball  or  < » 1 1 1 * •  i-  foreign  body  be 
left  until  suppuration  be  well  established.  Theu 
it  will  gradually  expose  it-  situation,  and  can 
1m-  much  more  readily  removed  than  during  the 
height  of  reaction,  when  the  parts  are  very  much 
swollen  and  very  painful.  The  surgeou  will  as- 
si-t  nature  in  the  expulsion  a-  gOOU  as  the  swell- 
ing lias  subsided  to  such  an  extent  that  the 
finger  or  the  forceps  can  again  be  introduced 
into   the   wound. 

The  above  rules  apply  chiefly  to  gunshot 
wounds  of  the  extremities \  those  of  the  trunk 
and    head   offer  so   many   exceptions   to    the  altove, 

ami  require,  in  a  measure,  such  special  treat- 
ment, that  the  course  to  he  pursued  in  such 
wounds,  complicated  with  foreign  bodies,  will 
he  specially  dealt  with  in  discussiug  special  in- 
juries. 

We  have  already  stated  that  fatal  hemorrhage, 
from  the  large  vessels  of  the  extremities,  does. 
not  often  occur  on  the  battle  Held  :  and  that 
when  such  arteries  are  wounded,  the  hemor- 
rhage   is    either    so    immediately     fatal    that     no 


INJURY    TO    LARUK    ARTKRIES.  IS, 

assistance  can  be  rendered,  or  it  ceases  sponta- 
neously. The  nervous  depression  so  common  to 
shot  wounds,  with  its  tendency  to  syncope,  and 
its  control  oyer  the  circulatory  organs,  ehecke 
the  impulse  and  supply  of  blood  through  the 
injured  vessel,  and  promotes  the  formation  of 
clots.     Openings  in  arteries  may  be  temporarily 

closed  by  foreign  Itodies.  and  in  such  cases  hem- 
orrhage would  recur  when  these  are  extracted. 
The  largest  arteries  may,  however,  be  wounded, 
and   may   cease    bleeding   spontaneously. 

The  only  means  of  detecting  the  injury  of  the 
Large  arteries  <>f  a  Limb  would  he  in  examining 
carefully  the  strength  of  pulsation  in  the  vessel, 
beyond  the  point  of  injury.  A  diminution  ol 
its  force,  when  compared  to  that  of  the  cor- 
responding vessej  in  the  opposite  limb,  shows 
conclusively  some  hindrance  to  the  circulation. 
When  m>  external  hemorrhage  exists,  an  ab- 
aence  of  pulsation  in  the  course  of  the  artery 
below  the  wound  is  the  only  means  of  detect- 
ing serious  injury  to  tin'  vessel,  and  it  often 
decides  whether  the  limb  should  be  at  once 
amputated.  The  presence  of  the  pulse  is,  of 
course,  no  indication  that  injury  has  not  been 
received. 

Although,    from    the    course    of    the    ball    and 


Is*  Lin  \  I  i  i;i\..    Ol     \i:  i  m:ii  - 

tin-  flow  of  blood,  we  know  that  the  main  v< 
of  the  limli  has  been  injured,  it'  the  bleeding 
■  1  -j niiit:iiM-«»u-l\ .  <»r  by  the  pressure  <»t' 
tin-  sponge,  or  compress,  which  was  tied  over 
the  wound,  the  artery  sliould  not  be  interfered 
wiili.  Iii  by  for  the  majority  of  cases,  if  proper 
precautions  be  taken,  there  will  he  no  recur- 
rence of  the  hemorrhage.  The  patient  should 
be  kepi  perfectly  quiet,  free  from  all  caus< 
excitement,  at  perfect  rest,  and,  fco  ensure  that 
the  limb  shall  not  be  moved,  a  bandage  Bhould 
be  carefully  applied  from  the  extremity  of  the 
liiuli  upward,  ami  a  long  splint  secured.  The 
flannel  bandage  being  the  in< >st  elastic,  is  fee 
beat  material  for  such  methodical  pressure  and 
support.  Elevation  of  the  limh  will  :i<l<l  much 
to  the  efficacy  of  the  preventive  treatment. 

'/'/,,  ligation  of  an  artery,  which  is  the  only  sure 
precaution  against  the  return  of  hemorrhage,  ra 
nnt  only  a  difficult  operation,  requiring  much 
skill  for  its  successful  performance,  hut  when 
isary  t<>  control  the  bleeding  from  b  recerrt 
wound,  In'. •Mine-  ;i  very  dangerous  one  to  the 
safety  of  the  limb  or  life  of  the  individual.  In 
of  < I i — « : » - « • .  nature,  always  <>n  the  alert, 
lia-  enlarged  contiguous  blood-vessels,  which  arc 
read\    to    assume    all    the    ftmctiona    of   tin'   one 


LIGATURING    OF    ARTERIES.  185) 

requiring  obliteration.  In  a  wound  in  a  healthy 
person  no  sucb  preparation  has  been  made;  and 
in  eutting  off  the  main  supply  of  blodd  through 
ji  limit  ii  becomes  a  very  serious  question,  often 
answered    by    the    loss   of   the    limb,   and    even 

life,  whether  the   circulation  will    he  -re-established 

in  time  to  save  the  member  from  mortifying. 
When  a  ligature  is  placed  upon  the  main  artery 
of  a  limb  for  disease,  previous  developments 
in  the  collateral  circulation  have  been  made  to 
sueh  an  extent,  that  the  extremity  may  not  even 
lose  temperature  after  the  ligation,  and  as  there 
is  no  diminution  of  the  nutrient  supply  there  is 
no  fear  of  mortification,  [f  placed  on  a  healthy 
vessel  for  an  injury,  the  limb  at  once  becomes 
pale  and  cold,  requiring  the  applicatidn  of  arti- 
ficial warmth  ami  enveloping  in  flannels  to  sup- 
port life  in  it  until  the  circulation  be*  re-estab- 
lished, when  the  limb  becomes  actually  warmer 
than  it>  colleague.  The  arterial  supply  is  now 
disseminated  in  vessels  much  nearer  to  the  SUV- 
fa>e  than  before,  where  its  chief  channel  was 
deeply  embedded  in  the  tissues. 

The  rapidity  of  this  collateral  development  in 
the  limb  is  well  exhibited  in  primary  and  see- 
ondary  amputation-.  When  a  thigh  is  amputat- 
ed   in   a   healthy    portion,    very    seldom    are    there 


li)0  LIOATI  KIM.    OF    AKTER1I  - 

more  thau  three  or  four  Ligatures  required,  to 
■top  all  oozing  ami  render  the  stomp  quite  dry. 
If  the  amputation  he  necessary  :it  the  same  point 
three  or  four  days  after  an  injury  to  the  main 
i  baa  been  received,  the  number  is  greatly 
increased:  as. many  a>  twenty-eight  arteries  have 
ligated  by  Langenbjeck  after  amputating  ;i 
thigh  under  similar  ciroumstani 

Should  active  hemorrhage  continue,  and  show 
no  disposition  to  cease,  the  wound  thould  bi 
dilated,  the  bleeding  mouths  of  the  artery  found, 
ami  a  lU/atim  applied  both  <i/">r,  <n,,l  />,/,, ,r  //,,  injury. 
This  has  become  the  fixed  practice,  and  the  only 
safe  one,  taking  its  place  among  the  aphorisms 
<>r  iurgery.  The  universal  adoption  of  this  prac- 
tice is  not  onlv  based  upon  experience  and  ob- 
servation, Imt  could  be  determined  a  priori  from 
the  physiology  ami  anatomical  distribution  of 
arteries. 

All  surgeons  arc  tarn i liar  with  the  anastomosis 
or  collateral  circulation  in  Mood  vessels.  When 
the  current  of  blood  is  stopped  at  any  otic  point, 
it  will  soon  find  its  way,  through  many  cirouit- 
oii>    routes,    back    to    the    very    point    at    which    its 

direct  course  had  been  checked.  When  an  ar- 
tery Is  divided,  it  is  well  known  that,  owing  to 
its  niii>cnlar   and    elastic   structure,    that    portion 


IJOATIUJINU    OF    ARTERIES.  IW 

above  the  wound  at  once  contracts  and  retracts, 
so  that  the  tube  which  was  before  cylindrical. 
now  resembles  a  claret  bottle  with  a  much  con- 
stricted neck.  A  dot  of  blood  soon  forms  in 
this  mouth  and  neck,  and  the  passage  of  the 
hlood  is  intercepted.  Jn  the  lower  portion  of 
tin'  divided  vessel  similar  changes  are  going  on, 
hut  not  to  so  great  an  extent.  The  contraction 
(owing  to  the  severing  of  the  nerves  which  give 
tone  to  the  arterial  walls)  is  only  partial,  the 
walls  being  to  a  certain  extent  paralyzed,  and 
so  little  hlood  remains  in  the  tube  that  a  very 
small   and   indifferent   clot   is  formed. 

When  the  upper  portion  of  the  artery  is  firm- 
ly closed,  preventing  all  egress  to  hlood,  the 
lower  portion  remains  patulous,  inviting  hemor- 
rhage. As  soon  as  the  Mood-currents  find  their 
way  by  circuitous  channels,  it  wells  up  from  the 
wound  in  a  continuous  purplish  stream,  all  im- 
pulse having  heen  lost,  and  also  most  of  the 
oxygen  contained  in  the  hlood,  by  the  long, 
roundabout  way  which  the  circulation  now  takes. 

The   darkness   of  the   hlood   will    depend   upon  the 

difficulties  of   the   circuitous   passage;    the   rule, 

however,  is:  .-carle:  or  arterial  blood  from  the 
upper  end  ^l'  the  vessel,  dark  colored  or  venous 
blood  from  its  lower  end. 


10*2  LTGATURTNO    or   ARTKH 

Guthrie   lays  down  tin-  two  following  rul< 
the  great  principles    "t"   surgery,  to    be   observed 
in    the   cases    of   wounded    arteries,    and    which 
ought  never  to  be  absent  from  the  mind  of  the 
surgeon  : 

1.  That  no  operation  ought  to  bt  performed  upon 
a  irnii nil,  il  artery  unless  it  bleeds. 

-_!.  Tfrnt  no  operation  is  to  I"  performed  for  <> 
wovvded  artery,  in  the  jirst  instance,  but  'if  thi  spot 
injured,  unless  sttch  operation  not  only  appears  to  be, 
hut  really  is,  impracticable. 

W  1km  it  is  necessary  to  ligate  an  artery,  the 
Burgeon  musl  be  guided  by  his  anatomical 
knowledge,  and  also  by  the  pulsation,  in  find- 
htg  it.  In  dilating  the  wound  so  as  to  expose 
the  bleeding  mouths,  the  incisions  should  be 
made  parallel  to  the  course  of  the  vessel,  and 
sufficiently  free  to  facilitate  the  search.  The 
dissection  is  carefully  conducted,  dividing  layer 
liy  layer",  and  avoiding  the  nerves  and  veins 
which  always  accompany  the  large  arteries. 
Wlic-n  the  bleeding  mouth  is  so  exposed  that 
the  origin  <>f  the  jet  of  blood  is  seen,  the  vessel 
i-  transfixed  by  a  tenaculum,  drawn  out,  and 
secured  as  it  would  be  in  a  stump  after  ampu- 
tation. 

When-  it   is  impossible  t<>    ligate  the   bleeding 


LIGATURING    OF    ARTERIES.  193 

vessel  at  tlic  point  wounded,  a  point  should  be 
selected,  at  which  the  vessel  is  comparatively 
isolated,  easily  diseovered,  and  lire  from  large 
collateral  branched.  Tn  exposing  it,  make  a  free 
incision.  The  common  mistake  that  most  sur- 
geons make  is  in  a  small  incision,  which  ham- 
pers the  search.  When  we  approach  the  artery, 
use  the  grooved  director  to  isolate  those  cellular 
layers  in  which  the  vessel  is  always  found.  The 
point  of  the  knife  should  never  he  used  for  this 
purpose.  The  lips  of  the  wound  should  be 
drawn  asunder  by  an  assistant,  so  as  to  give  to 
the  operator  the  light  necessary  for  accomplish- 
ing speedily,  and  successfully,  the  ligation.  In 
all  cases  requiring  such  an  operation,  it  is  de- 
sirable to  have  the  patient  completely  under 
control,  and,  therefore,  chloroform  should  be  ad- 
ministered. 

When  tin1  artery  is  found,  ami  the  ligature 
passed  under  it.  before  tying  it  be  quite  sure 
that  it  is  the  vessel,  and  it  alone,  and  not  the 
nerve  that  has  been  seized.  To  be  satisfied  on 
this  point,  it  is  only  necessary  to  draw  slightly 
upon  the  thread,  and  examine  above  and  below 
it  to  see  whether  the  pulsaliou  has  altogether 
d   below    the     ligature.      Having    determined 

that    the    thread    is   property    placed,   it    is    then 


11*4  I.K.All   U1M,     OF    AUTKKIKs. 

firmly  tied,  the  endi  arc  brought  out  pf  tlie 
wound  and  secured  under  a  strip  of  adhesive 
plaster,  attached  to  i  1m  •  immediate  neighborhood 
of  the  wound.  This  node  of  disposing  of  it  will 
protect  it  from  becoming  entangled  in  the  ordi- 
nary dressing,  and  from  being  drawn  upon  when 
these  are  dairy  removed.  Water  dressings  form 
the  proper  after-treatment.  The  thread  will  come 
away  spontaneously,  by  the  eighth,  twelfth  or  six- 
teenth day,  according  to  the  size  of  the  vessel 
ligated. 

When  ii  is  necessary  to  ligate  the  artery  in 
its  course  above  the  seat  of  hemorrhage,  I 
wop  Id  prefer  using  a  fine  silver  wire  ligature. 
This  is  well  twisted  upon  the  artery,  and  then 
<iit  oft",  leaving  only  the  Loop  with  one  or  two 
twists  in  the  wound.  The  advantage  is,  thai 
the  foreign  body  being  very  small,  not  weighing 
more  than  one-third  or  one-hall*  of"  a  u'rain, 
creates  hut  little  irritation,  and  the  wound  can 
be  healed  in  a  lew  davs  by  quick  union.  This 
will  protect  the  patient  from  the  dangers  of  sup- 
puration, )>v:emia.  or  secondary  hemorrhage  from 
the  ligated  point. 

In  the  treatment  of  reducible  inguinal  hernia, 
where  I  have  obtained  permanent  cures  by  sew- 
in",   the  columns  of  the    ring    together   by  silver 


LOCAL   TREATMENT    OF   WOUNDS.  195 

wire  sutures  passed  subcutaneousry,  the  small 
loo])  of  wire  remains  permanently  in  the  ingui- 
nal region  under  the  skin,  and  gives  no  trouble. 
From  experience,  in  limited  periods,  I  have  re* 
son  to  believe  that  it  will  remain  innocuous  for 
a  lifetime. 

The  silver  wire  shonld  not  be  applied  to  arte- 
ries in  ;i  suppurating  wound,  or  where  suppura- 
tion and  sloughing  must  ensue,  as  in  eleansing  the 
wound  it  would  be  liable  to  be  disturbed,  and 
mav  be  the  cause  of  bleeding.  Should  the  liga- 
tion of  the  large  arteries  at  the  root  of  the  neck 
ever  prove  successful,  it  must  be  by  the  adoption 
^i'  the  silver  wire  ligature,  which  can  be  twisted 
sufficiently  to  cause  a  certain  degree  of  irritation 
iu  the  outer  coats  of  the  artery,  and  induce  a 
copioui  deposit  of  lymph  for  incarcerating  the 
wire  and  thickening  these  coats,  without  caus- 
ing sloughing  of  the  inner  coats  or  opening  the 
vessel. 

Local  tr<<ii matt  of  wounds. — Saving  removed  all 
foreign  bodies,  and  hemorrhage  having  ceased, 
the  dressing  now  required  should  l>c  of  the  sim- 
plest description.  It  is  known  that  gunshot 
wounds,  belouing  t<>  the  contused  variety,  show  a 
constant   disposition    to   suppurate,   and  often    to 


LOCAL    Tin  \TMK\T    pf    WOUH  ' 

slough.        This   pr  partition 

sort/  to  the  heeding  of  0<<  wound,  and  should  In  kept 
in  subjection  "s  much  us  possible.  This  i-  effected  by 
iDtinued  application  of  cold  crater,  which,  by 
keeping  down  excessive  reaction,  and  keeping  <>ut 
;ui  excess  of  blood,  diminishes  the  source  of  the 
purulent  supply,  and  thus  hastens  the  cure.  Tn 
former  times,  suppuration  was  considered  essen- 
tial in  the  healing  of  all  wounds,  by  permitting 
the  escape  of  so  much  poisonous  matter,  which 
had  accumulated  in  the  system,  and  which  moat 
either  now  find  a  vent,  or,  it'  retained,  would  he 
considered  the  satisfactory  cause  of  any  sickness 
which  the  wounded  man  mav  ever  sutler  I'rom 
hereafter.  The  wound  was.  therefore,  plugged 
with  a  lint  tent,  piles  of  greasy  lint  in  cushions 
were  applied,  and,  after  covering  with  a  sufficient 
number  of  compresses  and  bandages,  a  forcing 
bed  was  formed,  which  supplied  pus  to  the  sat- 
isfaction of  all  interested;  and  it  was  common 
enough  to  see  life  drain  away  from  this  opening. 

This  smothering  Of  wounds  in  hot  poultices, 
and  the  smearing  on  of  greasy  ointments,  which 
the  wouuded  formerly  encountered,  was  a  second 
enemy,  far   more    fatal    than    the  enemy  on    the 

battle  field;   as  in   its   ranks   were   found   exhaust- 
ing   suppuration,  with    its    hectic:    pya?mia,  with 


WATER  DRESSING   ALWAYS  TO  BE  PREFERRED.       107 

its  rapid  pot&enisg ;  hospital  gangrene,  with  its 
sudden  collapse,  and  erysipelas,  with  its  thou- 
sands of  victims,  broken-down  constitutions,  te- 
dious convalescence,  very  protracted  cures,  and 
endless   pain    and   annoyance. 

How  much  more  rational  is  the  present  prac- 
tice. Keep  <may  nil  hot  dressings,  which  invite 
bluod  to  ih<  part.  Vote  poultices  and  greasy 
pledgets  a  curse,  and  eject  the  dirty,  trouble- 
some applications.  Guthrie  says  poultices  should 
not  he  permitted  in  a  military  hospital  :  they  are 
generally  cloaks  for  negligence,  and  sure  precur- 
sors of  amputation  in  all  serious  injuries.  With 
more  recent  writers  they  even  meet  with  less 
favor,  and  the  recent  experience  of  the  Rich- 
mond hospitals  is  not  averse  to  this  opinion. 

The  only  dressing  required  for  wounds,  of  whatever 
cluinicii  r.  is  the  water  dressing  and  it   should   be 

Heed  as  follows:  apply  a  single  thickness  of  wet 
linen  or  cotton  cloth  over  the  wound,  allowing 
it  to  extend  over  a  considerable  surface.  .It'  pos- 
sible, cover  this  with  a  layer  of  oiled  silk,  waxed 
cloth,  or  india-rubber  tissue.  A  second  layer  of 
cloth  or  a  band  seoures  the  two  former  Layers  in 
Position,  so   that    they   will    Hot    be  displaced   by   the 

movements  oi  the  patient  in  Bleeping.  Then, 
either   squeeze   cold   water  frequently   upon    this 


UlS       WATER    DRKSS1XU   ALWAYS  To  1!K   I'UKFKKH  Kl> 

outer  eloth,  which  will  keep  dp  the  low  tempe- 
rature; or,  adopt  the  much  more  convenient  and 
Less  Laborious  plan,  of  suspending  a  bucket,  er 
une  vessel  containing  water,  in  the  neighbor- 
hood of  the  w.nind.  having  ■  narrow  slip  of  cloth, 
or,  what  m  better;  a  lamp  wick  passing  through 
a  hole  in  the  bottom  of  the  suspended  vessel  to 
t Ik-  bandage  upon  the  wounded  liml>.  ISv  ca- 
pillary attraction,  a  constant  stream  of  water  is 
carried  from  the  vessel  to  the  dressing,  and.  by 
lie  evaporation,  robbing  the  skin  o€  its  animal 
temperature  to  get  a  sufficient  quantity  of  heat 
to  convert  the  water  into  aqueous  vapor,  it  re- 
frigerates the  Limb*  The  wick  must  run  freely 
through  the  hole,  but  not  boo  Loosely,  «  tlio 
water  will  flow  out  too  rapidly.  If  ir  pauses 
through  Bnugly,  so  as  to  Mock  up  the  orifice, 
capillary  action  will  not  draw  oil"  the  water,  and 
the  parts  will  not  he  irrigated.  The  advantage 
of  using  oiled  silk,  waxed  cloth,  or  india-rubber 
tissue  is,  that,  should  tin-  supply  of  water  acci- 
dentally    rr'wv    out    in     the    suspended     vessel,    the 

piece  of  cloth  beneath  it  remains  moist  upon  the 
wound.  The  wet  eloth  absorbs  the  discharges, 
and  should  he  changed  two  or  three  times  a  day, 
it  being  well  understood  that  they  he  disturbed 
Idoin  as  possible,  compatible  with  cleanliness. 


WATER   DRESSTXi;    ALWAYS  TO   BE  PREFERRED.       10!* 

The  surgeon  should  never  be  m  haste  to  change 
the  cold  for  warm  applications.  Should  the  vir- 
tue* of  a  poultice  be  called  into  requisition,  a 
soft,  wet  compress,  covered  with  oiled  silk  and 
secured  by  a  tlannel  roller  or  outer  compresfe,  is 
always  at  hand,  and  will  be  found  to  combine, 
in  a  simple  form,  all  the  properties  of  a  poultice. 
It  is  light,  moist,  soi't,  and  is  kept  warm  by  ab- 
sorbing animal  beat,  which  the  oiled  silk  and 
outer  compress  retain.  If  we  add  to  these, 
cleanliness,  facility  of  medication,  and  the  readi- 
ness with  which  an  impromptu  dressing  can  be 
made,  we  find  an  array  of  advantages  which  ex- 
clude all  substitutes. 

A  more  effectual  mode  of  keeping  down  reac- 
tion is,  by  using-  ice  bladders,  which  are  placed 
upon  the  india-rubber,  waxed  or  oiled  silk  cover- 
ing. These  are  of  very  general  application,  and 
make  the  least  call  upon  the  personal  attention  of 
nurses.  Whenever  ice  ie  used,  never  apply  it  directly 
io  tli<:  skin,  /'i/t  always  il<r<>'i<ih  the  intervention  of  cotn- 
s,  whicb  may  be  made  sufficiently  thick  to 
accommodate  the  application  to  the  sensitiveness 
of  the   patient.      When    possible,  these  bladders 

should  be  of  india-rubber  or  <rutta-percb;i  \ 
large  supply  of  these  should  always  be  on  hand. 
The   animal    bladder   is   ;i    miserable   substitute   as 


COLD    U  ATKR    THE    TROPEK    AI'I'LICAIU 

it  if  not  only  a  very  dirty  application,  allowing 
tin'  water  to  0O2e  «'Ut  and  keep  the  pat i»n t  con- 
stantly wet,  1'iit  tli«'  bladders  become  very  offen- 
sive, ami  arc  soon  destroyed. 

( '..!</  water  is  //<<  only  /'/•<</"/•  <ni<l  universal  antiphlo- 
gistic that  ca?i  bt  applied  to  wounds.  It  lias  the  con- 
venience of  always  being,  at  hand,  it  kiTj..-  up  a 
uniform  action,  is  clean,  simple,  cheap,  agreeable 
to  the  feelings  of  the  patient,  easily  obtained, 
easily  applied,  demands  leasl  care  from  the  nurses, 

who   have   their  hands   usually    full,  and   is   withal 

effectual.  With  the  judicious  application  of  cold, 
the  surgeon  can  defy  inflammation.  Cold  acts  by 
keeping  down  temperature,  constringing  vessels, 
and  keeping  blood  from  the  pari  injured;  so  that 
inflammation,  which  consists  in  the  engorgement 
of  Mood-vessels  and  an  excessive  supply  of  blood, 
cannot  gel  a  foothold.  Heat,  redness,  pain  and 
swelling,   all    depend   upon    congestion  ;    control 

the   supply   of  blood   to    a    part,   and    inilainination 

is  kepi  in   abeyance. 

As  the  advantages  of  cold  water  dressings  are 
obtained    through    the   evaporating   properties  of 

water,  this  action  may  he  increased  by  lnedi- 
eating  it  with  saline  substances  or  alcoholic 
tinctures.  Sugar  ^>i'  lead,  sulphate  of  zinc,  tan- 
nin, muriate  of  ammonia  or  laudanum,  spirits  of 


COLD    WATER    THE    1'RnT'l SB    APPLICATION.  201 

camphor,  and,  especially'  tincture  of  arnica,  would 
be  useful  adjuvants.  Borne  surgeons  consider  any 
addition  as  detrimental  to  the  efjicacy  of  simple 
water;  but,  unfortunately,  simplicity  is  but  little 
in  accordance  with  the  popular  taste. 

Whilst  the  irrigation  is  going  on,  the  com- 
presses next  the  skin  may  be  moistened  every 
tluve  or  four  hours  with  any  of  the  above  prep- 
arations. Should  the  wounded  p;itient  feel 
chilly,  the  cold  dressings  will  not  be  used  until 
reaction  lias  taken  place.  There  are  a  few  per- 
sons to  whom  the  application  of  cold  water  is 
inadmissible.  In  all  eases  the  feelings  of  the  pa- 
tient will  be  our  guide  as  to  the  applicability  of 
the  remedy.  When  not  grateful  and  refreshing 
to  the  patient,  but,  on  the  contrary,  the  c;mse  of 
complaints,  the  irrigation  must  be  superseded  by  a 
wet  compress,  covered  with  oiled  silk  or  a  waxed 
tloth.  This  will  soon  attain  the  temperature  of 
the  body,  and  wijl  keep  the  parts  moist  and  soft. 
The  dressing  requires  to  be  changed  twice  in 
twenty-four  hours;  not  that  the  compress  would 
get  dry,  for  the  perspiration  from  the  part,  which 
is  kepi  in  by  the  oiled  silk,  would  bathe  it  in  a. 
continual  and  permanent  moisture.  The  object 
in  ehanging  is  to  gel  rid  of  this  secretion,  which, 
in   decomposing,  would   irritate  the  wound. 


2<>2         POLD    watii:    Till-.    PROPM    Al'l'l.e   VTTOy. 

A  qnestim  of  great  moment  is,  when  should  m 
desist  from  water  applications  and  <■/. angt  for  sotm 
men  "<,  t',i I  or  appropriatt  dressing?  According  to 
the  present  rational  views  of  Burgeons,  no  other 
ling  is  ever  required,  however  serious  tin- 
wound  may  be.  As  long  as  inflammation  threat- 
ens, so  long  is  it  necessary  to  prevenl  engorge- 
ments. As  long  as  Buppuratidn  is  kepi  up,  so 
long  will  the  efftcacy  of  cold  be  required  to  con- 
Btringe  the  blood-vessels  and  control  the  source 
of  the  purulent  supply. 

Pus.  which  we  <-all  a  healthy  fluid,  is  m  heavy 
drain  upon  the  By  stem.  It  is  made  from  the 
richest  ingredients  of  the  blood,  which  were  id- 
tended  for  the  repair  of  tissues.  Once  converted 
into  pus,  it  is  unlit  for  any  further  useful  purpose, 
and  is,  therefore,  a  waste  of  precious  material. 
This  discharge  is  not  more  necessary  to  the  heal- 
ing of  wounds  than  to  the  nutrition  of  the  body. 
Extensive  wounds,  healing  by  the  first  intention. 
So  very  well  without  its  intervention.  Large 
subcutaneous  wounds,  when  eveu  their  sides  are 
not  kept  in  apposition,  heal  with  rapidity  with- 
out the  formation  of  pus.  Under  a  scab  we  find 
tissues  form,  by  what  has  been  called  the  re- 
modeling process,  without  it;  and  it  should  he 
our    constant    effort     to     heal    all    wound-,    and    I 


DISTURBING    INFLUENCES    or    W0UND8.  20o 

would  say.  especially  gunshot  wounds,  with  the 
least  possible  discharge.  Hence  the  water  dress- 
rag  can  be  continued  beneficially  for  -weeks,  or  as 
long  as  the  wound  remains  unhealed.  The  most 
recent  writers  on  gunshot  wounds  state  that  the 
wet  cloth  should  he  kept  on  until  cicatrization 
is  completed  ;  and  that  no  other  application  so 
protects  and  promotes  the  formation  of  new  skin. 

There  are  a  long  list  of  ointments  which  have 
heretofore  held  universal  sway  in  the  treatment 
o!'  wounds.  All  oi'  these  can  he  dispensed  with 
for  the  more  simple  dressing.  Should  the  wound 
require  stimulation,  the  nitrate  <,)['  silver  wash, 
irrs.  xx  to  the  ounce,  when  brushed  over  the  part, 
will  suffice;  or  tincture  of  iodine,  or  iron,  or  some 
stimulating  astringent,  might  be  equally  applied 
in  addition  to  the  water  dressing,  so  that  any 
imaginary  condition  of  the  wound  might  be 
successfully  met  by  the  medicated  we*  doth. 

The  disturbing  influences  in  the  healing  pro- 
cess of  wounds  are  numerous,  and  most  of  them 
arc  capable  ^\'  correction  without  much  trouble. 
Among  these  are  found  imperfect  transportation 
orer  rough  roads  in  improper  vehicles:  had  at- 
tendance, Buch  as  rough  or  too  frequent  examina- 
tions; useless  bandaging,  which  promotes  infil- 
tration;   too   frequent    dreseiug ;   improper    food: 


2(»4  SU  OOND  U'.Y     Hl'MulMUl  I 

scorbutic,  syphilitic,  and  other  diseases ;  the  moral 
depression  of  defeat,  and,  above  all,  the  imper- 
fect ventilation  and  insufficient  regard  to  clean- 
Linese  in  the  wards  of  military  hospitals. 

W  e  have  already  said  thai  a  surgeon  is  never 
warranted  in  cutting  down  upon  an  artery  and 
tying  it  upon  suspicion — he  must  be  an  eye-wit- 
of  t!i<'  hemorrhage,  and  see  that  it  cannot 
be  controlled  by  other  means.  The  ligation  of 
an  artery  is  always  a  troublesome  operation,  and 
from  the  fear  of  subsequent  mortification,  always 
jeopards  the  limb,  and  necessarily  with  it  the 
lite  of  the  patient.  This  is  specially  the  ease  in 
recent  wounds,  before  nature  has  prepared  a  col- 
lateral circulation,  bo  that  the  rule  which  we  have 
laid  down  is  imperative — never  ligate  an  artery, 
however  large,  in  which  hemorrhage  has  spontane- 
ously ceased j  and,  moreover,  that  a  good  com- 
press is  usually  sufficient,  when  applied  imme- 
diately after  the  Receipt  of  injury  on  the  battle 
field,  to  stop  the  bleeding  even  from  the  Largest 

vessels,    &nd    that     position,   quiet,    rest,   and    other 

prophylactics  will  prevent  its  return. 

In  the  ordinary  course  of  u'tinshot  wounds, 
suppuration  is  established  about  the  fifth  or  sixth 
day.  when  the  track  of  the  wound  commences 
in    be   cleansed   of  all    those    tissues   which    have 


SECONDARY    HEMORRHAGE.  205 

been  crushed,  and  so  much  injured  as  to  be  no 
longer  preserved  among  the  living  tissues;  Dur- 
ing  the    elimination    of   these    destroyed    parte, 

where  the  precaution  of  rest  and  absolute  <[uiet 
lias  not  been  enforced,  hemorrhage,  called  sec- 
ondary, appears.  All  injuries  to  large  arteries 
threaten,  sooner  or  later,  to  produce  secondary 
hemorrhage.  However  large  the  artery  reopened 
by  tins  process,  the  escape  of  blood  seldom  oc- 
curs with  an  impulse,  but  flows  away  in  a-  con- 
tinuous stream,  which  marks  its  escape  from  the 
lower  end  of  the  vessel. 

When  hemorrhage,  even  from  the  femoral  ar- 
tery, has  been  arrested  for  twelve  hours,  the 
efforts  of  nature  are  usually  sufficient  to  prevent 
it>  return  from  the  upper  portion  of  the  artery, 
although  not  from  the  lower  end  of  the  vessel  ; 
so  that  when  the  main  vessel  of  a  limb  is  divided 
by  a  ball,  should  primary  hemorrhage  be  control- 
led, the  great  fear  is  from  bleeding  through  the 
lower  end  of  the  artery,  and  from  mortification  of 
the  extremity.  Any  hemorrhage,  after  twenty-four 
hours.  w<>uld  be  considered  secondary,  and  would 
require  special  treatment.  As  long  as  the  wound 
remains  open,  hemorrhage  may  make  its  appear- 
ance; and  il  is  not  until  a  cure  is  effected  and 
the  parti  are  ewartrt#eu\  that   the  patient  is  posi- 


/ 


206        HEMORRHAGE  FROM   LOWRR   HMD  Of  ART]  RY. 

tivclv  safe  from  this  dangerous  complication. 
Cases  are  recorded  where  it  haa  occurred  ninety 
<1m\  -  after  the  vessel  bad  received  injury.  Unless 
the  causes  of  this  hemorrhage  be  perfectly  un- 
derstood,  the  rules  laid  down  for  treatment  will 
not  be  duly  appreciated. 

In  speaking  of  the  action  of  the  two  ends  of 
a  divided  artery,  we  have  already  stated  that 
the  upper  end  contracts  vigorously,  diminishes 
its  calibre  at  the  mouth,  and  Got  some  distance 
up  the  tube,  until  it  simulates  in  its  proportions 
the  neck  and  body  of  a  claret  bottle.     The  hlood, 

impeded  in  its  outward  course,  allows  a  dot  to 
form,    which,    acting    a-    a    Stopper,    shuts     up    the 

open  mouth.  The  plug  is  continued  in  the  con- 
tracted artery  to  the  first  collateral  branch  as  a 
clot  of  blood,  which  nearly  tills  its  cylinder.     The 

lower  portion  of  the  vessel,  having  been  in  a 
measure  paralyzed  by  tin-   division  of  its  coats, 

which  had  cut  oil"  its  supply  of  nerves,  acta  with 
much  Less  energy.  The  diminution  of  its  calihre 
depends  more  upon  the  removal  of  distension 
from  its  elastic  walls  than  from  the  contraction 
of  its  muscular  fibres,  The  result  is.  that  it  re- 
mains  more   or   less   patulous  ;   and    as    the   supply 

of  blood  from  above  is  cut  otf.  there  is  hut  Little 
arterial   Mood   in    it    to  clot   and  plug  it    up. 


iikmoiuwiack  from  lower  end  of  artery.      20< 

As  soon  as  tliis  barrier  or  clot  is  placed  uppu 
tlie  main  thoroughfare,  at  the  upper  wound.  pre- 
venting the  blood  from  following  its  accustomed 
channel,  nature  is  at  once  busy,  opening  and  en- 
larging the  circuitous  by-ways  and  alleys  of  the 
circulation,  so  as  to  restore  the  supply  to  the  ex- 
tremity threatened  with  starvation,  or,  in  surgical 
parlance,  mortification.  As  when  upon  a  high- 
road a  bridge  spanning  a  stream  is  destroyed, 
travellers  seek  a  lord  higher  up  by  which  they 
may  return  to  the  thoroughfare  beyond  the  im- 
pediment, so  the  blood,  taking  the  nearest  by- 
roads above,  soon  gets  around  the  obstacle,  and 
empties  itself  into  the  main  channel  below  it. 
The  blood  here  changed!  in  its  direction,  and  not 
opposed  by  valves,  passes  up  as  well  as  down 
the  limb,  and  finding  an  open  gate  at  the  lower 
torn    mouth    of    the    vessel,    escapes.       This  fluid, 

moreover,  in  its  roundabout  course,  lias  lost  much 
of  its  vivifying  properties;  much  of  its  oxygen 
is  gone,  and  carbonic  acid,  ammoniacal  gases  and 
the  like,  having  taken  its  place,  mars  its  brilliant 
color,  and  diminishes  its  clotting  properties.  No 
proper  material  exists  for  stopping  up  the  vessel, 
as  in  tin'  upper  end  of  the  divided  artery,  and 
the  result  i>.  that  secondary  hemorrhage  nearly 
always  occurs   from   the   Lower  end. 


TRKATMKNT    OF    BECONDARY    11  I  M"i:  !<  M  \. .  K 

This  befog  well  understood,  we  can  now  eoc- 
jilaiii  why  a  ligature  placed  on  the  upper  orifice 
alone,  or  on   the  course  of  the  artery  above  the 

injury,  should  not  stop  hut  only  temporarily  con- 
trol the  hemorrhage.  A-  Boon  aa  the  collateral 
circulation  above  the  ligated  poinl  is  re-estab- 
lished, the  lower  opening  in  the  vessel  remaining 
as  before,  hemorrhage  musl  recur,  or,  if  this  cir- 
culation is  not  re-established,  mortification  must 
follow.  The  rale,  thkn,  is  w/vpetatbn  :  Hyatt  both  ends 
of  fin  vessel  at  th  point  woutoded;  this  is  thx  ovtttj 
saf<   coursi   tb  pursue. 

Another  Btroflg  reason  why  the  Kgature  should 
be  applied  to  the  wounded  ends  of  the  artery  is, 
that  there  is  always  BOme  uncertainty  as  to  the 
vessel    injured.      The   very   >erious   and   often    fatal 

operation  of  ligating  the  femoral  artery  has  been 
performed  for  an  injury  to  one  o\'  its  branches, 
which  had  not  been  suspected— a  post- mortem 
examination  revealiiig  the  source  of  hemorrhage. 
When  the  ligature  is  applied  to  the  bleeding 
mouths,   this  accident   cannot   happen. 

The  course  which  should  be  adopted  in  il<<  cast  of 
hemorrhage  from  "n  injured  artery,  is  as  follows: 
After  the  hemorrhage  lias  once  been  controlled, 
and    through   either   eafelesshess  on  the  part   of 

the     BUrgeOIl     or    restlessness     on     the     pkri     of    the 


TREATMENT    OF    SKCONDARY    HEMORRHAGE.  209 

patient,  getting  up  to  help  himself  when  he 
had  strict  orders  to  the  contrary,  etc.j  or  per- 
1ki}is  from  rough  transportation  over  bad  roads, 
or  the  sloughing  of  the  wound,  hemorrhage  re- 
appears, the  limb  should  be  at  once  bandaged 
from  the  extremity  upward,  making  careful,  negu- 
lar  pressure,  so  as  to  diminish  the  quantity  of 
circulating  fluid.  Over  the  course  of  the  main 
artery,  and  for  some  little  distance  above  and 
below  the  wound,  a  compress,  saturated  or  not 
with  some  of  the  styptic  preparations  of  iron, 
should  he  firmly  secured:  the  bandaging  of  the 
limb  extending  to  one  or  two  inches  above  the 
injury.  The  patient  is  then  to  he  placed  upon 
his  bock,  the  limb  elevated,  and  an  ice  bladder 
applied  over  tin1  wound.  Absolute  quiet  should 
be  enjoined,  and  secured  by  administering  a,  Large 

dose    of  Opium; 

Tn  many  cases,  this  dressing  will  bring  about 
the  desired  object,  when  assisted  by  those  in. 
ternal  remedies  which  control  the  force  of  the 
circulation,  as  veratrurd  viride,  digitalis,  etc.     By 

the  use  of  compresses  saturated  with  the  per 
chloride  of  iron,  in  connection  with  absolute 
rest.  I  have  succeeded  in  checking  secondary 
hemorrhage  from  the  carotid  artery  after  the 
e  cape  of  the  ligature. 
is 


L'l<'         TREATMENT    OF    SECONDARY    HEMORRHAGE. 

"Rut  should  the  parts  be  bo  situated  that  this 
pressure  cannot  be  applied  for  ;i  suftcientiy  long 
time,  or  should  it  n<>i  control  the  bleeding,  then 
the  proper  course  If  to  ligate  the  mouth-  of 
the  artery  in  the  wound  without   farther  delay. 

No  case  of  secondary  hemorrhage  should  de- 
stroy life  by  repeated  recurrence;  a  surgeon  is 
very  culpable  who  permits  lift  to  ehfe  away  from 
his  grasp. 

Physicians  cannot  be  too  guarded  against  the 
delusive  attempts  at  stopping  the  bleeding  after 
the    recurrence   of  secondary   hemorrhage:    it   is 

certain    to    return    and    Certain    to    destroy    lite,    as 

experience  has  repeatedly  proved.  Every  fresh 
hemorrhage  increases  the  dangers  and  multiplies 
the  risks;  therefore^  never  neglect  /i;/>//in</  t/>>  artery 
after  the  second  hemorrhage. 

You  must  not  be  deterred  from  placing  n  liga- 
ture on  the  open  mouths  of  an  artery  in  a  sup- 
purating wound,  on  the  deeply  grounded,  but 
erroneous  idea,  that  the  artery  has  had  its  coats 
softened  by  this  process.  Practical  surgery  shows 
conclusively,  that  the  coats  are  tough  enough  to 
sustain    a    ligature   in    a    suppurating   wound,    and. 

therefore,  the  rule  should  have  no  exception. 
Tjidah  in  the  wound  under  >nt>/  cfrcitmst^nces,  n-jun 
it    is    'possible.      The    swelling    and    infiltration    of 


TREATMENT    OF    SECONDARY    HEMORRHAGE.  21  1 

tissues,  renders  the  search  after  the  injured  ar- 
tery difficult;  but  the  surgeon,  who,  looking  to 
the  side  of  humanity,  considers  it  a  sacred  duty 
to  do  everything  for  the  interest  of  the  wound- 
ed, must  not  allow  difficulties  to  interfere  with 
Ins  proper  course.  Safety  lies  alone  in  this 
operation.  The  difficulties  must  be  met  and 
overcome. 

The  following  appearances  will  he  observed  in 
the  wound,  and  will  assist  in  the  search  :  After 
dividing  the  infiltrated  tissues,  should  the  in- 
jury have  heen  received  over  forty-eight  hours, 
particularly  if  five  or  six  days  have  intervened, 
the  ends  of  the  vessel  will  he  found  incarcerated 
in  a  mass  of  greenish  yellow  fihrine,  which  indi- 
cates, in  a  remarkable  manner,  their  situation. 
That  which  conceals  the  lower  mouth  of  the 
vessel  is  always  in  smaller  quantity.  Where 
post-mortem  examinations  are  made,  a  probe  in- 
troduced into  the  artery  from  below  would  make 
its  appearance  at  a  point  under  the  yellow 
patch,  raising  a  thin  portion  as  it  protrudes; 
and  should  the  patient  have  been  destroyed  by 
secondary  hemorrhage,  an  opening  will  usually 
he  found  in  tliis  pellicle.  Through  the  upper 
portion  of  the  artery  the  probe  would  pass  down 
with     much     more    difficulty,     owing    to     a     con- 


212        THKATMl.NT    Of    BBOOMDAET    RMOBftKAOS. 

| 

tracted  tube  plugged  with  coagula — conditions 
which  do  not  exist  in  the  lower  portion.  These 
lymphy,  yellowish  green  spots  are,  then,  mh 
guides  after  the  wound   baa  beeu   freely  diluted. 

In  a  surgical  operation,  especially  in  ligating 
arteries,  never  eramp  onesself  from  the  Gear  of 
making  t < ►< »  large  an  opening;  the  error  is  al- 
ways on  the  other  side.  Having  found  and 
ligated  the  orifices,  the  water  dressing  should 
be  continued  as  before  —  care  being  taken  not 
to  apply  it  should  the  Kmh  become  cool  and 
pale.  This  is  not  usually  the  ease  after  second- 
ary hemorrhage,  for  the  return  of  the  bleed* 
ing  indicates  a  re-estahlished  circulation,  which 
the  ligature  at  the  bleeding  mouths  cannot  now 
influence    to   the   injury  of  the   Limb. 

Should  it  be  impossible  to  find  the  bleeding 
mouths,  after  a  long  and  careful  search,  then  wo 
will  he  reluctantly  compelled  to   adopt   the   Leu 

satisfactory  operation  of  ligating  the   artery  ahove 

tli'-  wound — hoping  it  may  obviate  any  further 
operation,  often,  however,  when  this  last  plan 
has  been  adopted,  a  return  of  the  hemorrhage 
necessitates  a  second  ligature  upon  some  higher 
point:  and  should  this  fail,  as  is  often  the  case, 
amputatiqp  of  the  limit  will  he  the  only  resort 
to    save    life.       Amputation    must    he    equally    re- 


TREATMENT    OF    SECONDARY    HEMORRHAGE.  2b> 

sorted  to  if,  after  the  application  of  a  ligature, 
the  circulation  not  being  re-established,  morti- 
fication of  the  limb  ensues.  In  either  case  am- 
putate above  the  seat  of  the  ligature,  so  as  to 
ensure  a  supply  ©f  blood  to  the  stump  for  its 
nutrition. 

These  are  some  of  the  dangers  incurred  when 
the  surgeon  does  not  adopt  the  only  proper 
course  to  stop  the  trouble  at  its  eommeuce- 
ment.  Military  hospital  statistics  show  heavy 
mortuary  lists  where  this  rule  is  not  recognized 
and  followed.  As  the  ligature  acts  as  a  for* 
eign  body,  and  must  come  away,  it  is  of  little 
importance  what  is  used  for  that  purpose,  a 
strong  cotton,  flax  or  silk  thread,  fulfils  all  the 
indications  required.  When  applied,  it  should 
not  be  interfered  with,  until  it  has  either  come 
away  of  its  own  accord,  or  ten  to  fifteen  days 
have  elapsed,  when  cautious  tractions  might  be 
attempted    to    hasten   its   removal. 

Silver  wire  has  been  spoken  of  as  ligatures 
for  arteries.  However  well  it  may  answer  in 
fresh  pounds,  where  union  by  the  first  inten- 
tion can  be  obtained,  it  is  quite  out  of  place  in 
suppurating  wounds,  as  when  ligatures  are  ap- 
plied  for  controlling   secondary   hemorrhage. 


214  PI   Hi    M   K  Kit     \\  nl    \ 

PlJlfOTUmED    WOUNDS     MADE     Bl     TUT    BATONBT    OR 

babeb,  require  similar  treatment  a<  in  gunshot 
wounds,  [f  1 1n-  hietory  and  appearances  clearly 
indicate  the  character  of  the  wound,  there  will 
be  no  need  of  probing  for  imaginary  foreign 
bodies.  Such  wounds  usually  bleed  more  freely 
than  gunshot  wounds,  but  the  hemorrhage  is 
susceptible  of  control  by  similar  means;  press- 
ure being  preferred  to  ligation  of  arteries.  The 
treatment  should  be  cold  wain-  dressings  —  irri- 
gation preferred.  Protect  the  wound  from  air, 
if  possible,  by  covering  it  with  adhesive  plaster, 
or  collodion,  and  dress  it  as  seldom  as  possible, 
compatibli  with  cleanliness.  Onci  probing  of  Buch 
a  wound  should  satisfy  the  curiosity  of  any  sur- 
geon.  A  frequent  repetition  of  this  meddlesome 
snrgery,  besides  the  needless  pain  inflicted  upon 
id.'  wounded  man,  must  end  in  mischief. 

Should  ;i  bayonet  <>r  sabre  wound  transfix  one 
of  the  natural  cavities,  the  internal  injury  mav 
be  rapidly  fatal  from  hemorrhage,  qt  the  injury 
iuflicted   ii] ><>n  the  contained  organs  may,  sooner 

or   later,    lead   to    the    destruction  of   the    wounded 

by   viscera]   inflammation.     Under   ordinary    con- 
dition-,  when   such    wounds  exist    ill   the  extrem- 
where    no     large    vessels    are     implicated, 
they  require  no  special  treatment.     Ii    is  a  class 


rUNCTUREP    WOT'NDS. 


215 


of  wounds  not  as  frequently  met  with  in  mili- 
tary surgery  as  one  would  suppose.  The  newly 
introduced  sabre-bayonet,  when  plunged  into  the 
body,  leaves  l>ut  little  work  for  the  surgeon. 
Siidi   eases  seldom  leave  the   battle  field  alive. 

WTien  the  ordinary  bayonet  lias  buried  itself 
deeply  in  a  limb,  suppuration  may  appeal-  in 
the  march  of  the  wound.  Should  pus  be  sus- 
pected, and  fears  exist  that  it  may  be  pent  up 
under  a  fascia,  to  permit  of  its  tree  escape,  it 
would  be  necessary  to  dilate  the  -wound.  Under 
no  other  condition,  except  Ibr  serious  hemor- 
rhage,   where    it    is    necessary    to    Kgattt    the    open 

mouths  of  the  bleeding  vessel,  should  a  punc- 
tured wound  made  by  either  sword  or  bayonet 
be  dilated. 

Simple  incised  wounds,  as  sabre  cuts,  will  be 
closed    by  adhesive  plaster   (or  sutures,  which   arc 

preferable,  should  there  be  any  tendency  to  gap- 
ing),  to  be  followed  by  the  cold  water  dressing. 
Sbould  the  wound  be  not  of  a  serious  charac- 
ter, it  may  be  left  even  without  after-dressing — 
the  little  oozing  from  its  edges,  when  drawn 
together  by  straps  or  sutures,  dries  into  a  scab 
along  tin'  line  of  wound,  and  excludes  air  with 
its  pernicious  influences.  This  permits  of  the 
remodelling  process,  and  cicatrization  i<  effected 
without  suppuration. 


218  GENERAL    TIO.ATM  K.NT    8f    W0UND8. 

In  gunshot  wounds,  the  swelling  which  shows 
itself  a  few  horns  after  the  injury  has  been  re- 
ceived, continues  increasing  until  the  comple- 
tion of  the  third  day,  when  it  has  attained  its 
acme  with  commencing  suppuration.  Should 
sloughing  occur,  it  will  show  itself  by  the  >i\th 
or  seventh.  (>n  the  eighth  or  ninth  day,  the 
slough  has  in  most  cases  separated  itself  from 
tlw  edges  of  the  track  of  the  ball,  and  in  a  few 
•  lavs  more  will  have  been  disengaged.  With 
the  cleansing  of  the  wound,  the  inflammation 
gradually  subsides,  the  swelling  diminishes,  puru- 
lent discharge  lessens  in  quantity,  and  the  wound 
commences  contracting.  The  middle  portion  of 
the  track  tirst  closes,  and  with  it  the  opening 
of  exit,  leaving  a  funnel-shaped  canal,  which  di- 
minishes from  day  to  day,  becoming  more  -n- 
perficial,  until  no  depth  is  left  to  the  orifice  of 
entrance,  which  cicatrizes  with  a  depression, 
marking  distinctly  the  nature  of  the  injury 
which  has  been  received.  This  is  the  ordinary 
course  which  gunshot  wounds  take  when  judi- 
ciously treated  in  good  constitutions. 

In  th<  general  treatmeni  of  such  <-a-cs.  interfere 
with  the  general  health  as  little  as  possible. 
'I 'he  commonly  prescribed  antiphlogistic  reme- 
dies are.   with   hut   few  exceptions,   not   required. 


OENERAL    TREATMENT    OF    WOUNDS.  217 

The  endless  list  of  emetics,  purgatives,  diuretics 

and  diaphoretics,  to  which  sonic  European  writers 
still  cling  with  wonderful  tenacity,  can  be  bene- 
ficially dispensed   with. 

Guthrie,  who  represents  this  class,  in  speaking 
of  the  inflamed  stage  of  gunshot  wounds.  Bays, 
that  the  treatment  for  subduing  this  should  be 
active:  "the  patient,  if  robust,  ought  to  he  bled 
(if  no  endemic  disease  prevails),  vomited,  purged, 
k<'pt  in  tlic  recumbent  position,  and  cold  applied 
as  long  as  it  shall  be  found  agreeable  to  his 
feelings;  when  that  ceases  to  be  the  case,  warm 
fomentations  ought  to  be  resorted  to,,  but  they 
are  to  be  abandoned  the  instant  the  inflammation 
is  subdued   and   suppuration   well   established." 

We  believe  active  purgation  and  vomiting  to 
be  incompatible  with  that  degreee  of  quiet  which 
is  laid  down  as  a  fundamental  rule  in  the  treat- 
ment of  gunshot  wounds.  As  suppuration  is 
usually  long  continued,  and  debility,  with  a  cer- 
tain degree  of  emaciation,  usually  accompanies 
the  march  of  gunshot  wounds,  the  disposition 
should  rather  be  to  harbor  strength  to  support 
this  drain  than  to  despoil  the  system.  The  mod- 
ern practice  of  support  rather  than  depletion 
hastens  convalesce. noe,  and  is  the  only  rational 
praei 


L' 1  x  GENERAL    TREATMENT    Of    WOUNDS. 

General  and  local  bloodletting  are  oal)  per 
quired  in  ■  t'<'\\  special  injuries  of  particular 
organs,  which  will  be  hereafter  mentioned. 

Emetics,  a>  such,  arc  never  required  in  the 
genera]  treatment  of  wounds.  When  very  small 
doses  of  the  emetic  preparations  are  given*  to 
induce  relaxation  and  for  generalizing  the  circu- 
lation, in  this  way  deriving  the  excess  of  Mood 
from  the  wound,  they  may  be  useful.  Small 
doses  of  tartar  emetic  may,  with  other  remedies, 
form  a  good  prescription  in  cases  of  excessive 
reaction.  Mild  purgatives  are  in  constant  ie<|iii- 
sition,  hoth  for  their  detergent  as  well  as  deriv- 
ator^- effects. 

The  granulations  of  a  wound  are  said  to  be  a 
better  index  of  the  condition  of  the  intestinal 
•  •anal  than  the  tongue,  as  they  arc  much  more 
readily  influenced    by  any  cause   which  induces  an 

irritable  condition  of  the  system.  Keeping  watch 
aver  the  digestive  organs;  preventing,  by  prop- 
er diet,  any  indigestible  fond  from  getting  into 
them,  whilst  the  excretions  which  empty  into 
this  great  sewer  are  not  allowed  to  remain  and 
disturb  the  system,  will  he  at  all  times  judi- 
cious practice.  Diaphoretics  and  diuretics  are 
the    milder    antiphlogistic    and    derivative    reme- 


GENERAL    TREATMENT    OP    WOUNDS.  219 

•  lies,  which  may  frequently  be  called  upon  to 
quiet  the  pulse  and  equalize  the  circulation. 

The  ordinary  febrile  reaction,  which  so  fre- 
quently follows  the  receipt  of  severe  injury, 
should  give  the  surgeon  no  annoyance  /><  r  se, 
It  is  only  a  symptom;  an  indication  of  the  ex- 
tent of  sympathy  between  the  local  irritation 
and  the  system  at  large.  When,  by  judicious 
local  treatment,  the  nervous  excitement  near  the 
wound  subsides,  the  pulse  will  pari  passu  lose 
its  frequency  and  irritability.  It  is  not  a  disease 
within  itself,  requiring  to  be  especially  attacked. 

In  the  general  treatment  of  wounds,  diet  ami 
rest  are  the  two  great  remedies,  which,  in  by  far 
the  majority  of  wounds,  even  the  most  serious, 
ace  all  that  is  required  for  successful  treatment. 
Should  there  be  an  excess  of  general  excite- 
ment, which  a  purge  with  a  diaphoretic  or  diu- 
retic is  not  able  to  quiet,  we  would  administer 
to  such,  some  one  of  that  class  of  medicines 
which  are  known  to  control  the  excitement  of 
the  circulation,  quiet  the  brain,  and  act  as  M& 
utives  upon  the  nervous  system  generally,  viz: 
opium,  hyoseyamus.  coniuni,  belladonna,  digi- 
tals, veratrum  viride,  etc. 

When  local  reaction  is  excessive,  with  great 
swelling  and    heat,  there  is  a  class  of   medicines 


122U  UKNKRAL    TRKATMF.NT    OF    WOIN 

which  might  be  given  with  advantage.  They 
act  by  increasing  the  tone  of  blood-vessels,  ami 
thereby  cause  a  contraction  in  their  walls  and 
diminution  of  their  calibre.  Upon  such  reme- 
dies much  reliance  might  be  placed.  Among 
these  are  found  the  mar.  tinct.  bf  iron,  tinct. 
of  belladonna,  wine  of  ergot,  and  others,  which 
play  ;i  conspicuous  part.  It  is  by  contracting 
ilie  blood-vessels  to  such  an  extent  that  a  suffi- 
cient supply  of  blood  cannot  be  transmitted  for 
the  nourishment  of  distant  tissues,  that  mortifi- 
cation follows  the  too  libera]  and  long-continued 
nse  of  ergot.  By  tins  property  of  producing 
contraction  in  blood-vessels,  uterine  hemorrhages 
are  checked,  or  the  action  of  the  gravid  womb, 
with  its  immensely  developed  blood-vessels,  ex- 
cited. The  entire  profession  have  adopted  iluv 
mnr.  tinct.  of  iron  as  nearly  a  specific,  against 
the  fearful  inflammatory  reaction  of  erysipelas^ 
for  stronger  reasons,  it  is  equally  efficacious  in 
simple  inflammatory  engorgements.  Belladonna 
shows  its  general  action  by  dilating  the  pupil — 
an  effect  explained  by  the  change  in  the  circu- 
lation of  the  blood-ve8Sels  of  the  iris.  Its  ad- 
vantages in  relieving  injection  of  the  blood-ves- 
sels  of  the  eye  are  well  known  and  largely  used. 
It   is  spoken  of  as  the    remedy  for  the  rapid   re- 


GENERAL    TREATMENT   OF    WOUNDS*  221 

lief  of  congestion  of  the  spina]  cord.  Although 
these  are  the  individual  effects  of  such  remedies, 
ilu'v  are  not  the  specific  action  i)\'  these  medi- 
cines. Their  influence  belongs  to  the  economy; 
and  in  affecting  all  the  tissues,  those  feel  their 
influence  most  which  are  offending,  as  there 
would  he  the  widest  field  for  the  remedy  to 
show  its  common  effects. 

Inflammation  is  a  perverted  condition  of  the 
blood  and  blood-vessels  of  a  part,  which  means 
a  modified  state  of  nutrition.  There  are  two 
diametrically  opposed  means  of  correcting  this 
condition  and  restoring  health.  One  is,  by  re- 
ducing the  amount  of  blood  carried  to  the  part 
which  threatens  to  overwhelm  the  vital  functions 
of  such  an  inflamed  portion  of  the  body.  This 
is  effected  by  bloodletting,  vomiting,  purgation, 
abstemious  diet,  and  the  entire  list  of  depletory 
or  spoliative  remedies,  which  weaken  the  enemy 
to  such  an  extent  as  to  allow  of  the  part  at- 
tacked successfully  coping  with  the  disease.  I'>ut 
when  the  disease  is  conquered,  the  victory  may 
he  as  disastrous  as  a  defeat,  a  Long  convalescence 
being  required  to  restore  the  patient  to  Ins 
former  stale  of  health.  The  other  method  is,  by 
increasing  the  tone,  both  of  part  and  system.  !>y 
supporting  agents  which  strengthen  the  garrison, 


222  GENERAL    TREATMENT    OF    WOUNDS. 

increase  the  vital  powers  residing  within  the 
tissues  for  resisting  the  encroachments  of  disease, 
and    thus   are  enabled    to  drive    out    the  enemy, 

however  violently  the  attack  may  be  made. 
These  successes  are  attained  with   but   little  loss 

Oil  the  part  Of  the  system,  which  comes  out  of 
the  tire  unscathed.  Our  object,  then,  should  al- 
ways be  to  cure  disease  by  using  such  remedies 
as  will  cause  the  least  possible  loss  to  the 
economy. 

In  all  injuries,  were  it  not  for  an  exquisitely 
sensitive  nervous  system,  we  would  have  hut 
little  systemic  sympathy,  and.  therefore,  but  little 
personal  annoyance.  In  the  inferior  animals, 
whose  sensibilities  are  of  a  low  description,  limbs 
can  he  torn  off  without  deleterious  effect,  and 
without  producing  inflammation.  These  inflam- 
matory tendencies  are  only  observed  as  we  ad- 
vance in  the  scale  of  animal  life,  until  we  find 
in  man  a  perfection  of  a  nervous  system,  with 
its  corresponding  susceptibilities  to  physiological 
as  well  as  pathological  impressions.  If  we  could, 
by  some  metamorphosis  in  man,  temporarily 
revert  to  the  more  primitive  developments,  we 
would  diminish  the  dangers  of  local  trouble  :  Of 
if  we  could  take  possession,  as  it  were,  of  the 
nervous    functions,    and     reduce    them    to    their 


BNDBRMIC    ISK    OF    MORPHINE.  '22'-) 

lowest  stage  tor  extending  sympathies,  we  could 
equally  keep  down  irritation,  and  to  a  great  ex- 
tent jugulate  the  tendency  to  congestion,  and, 
subsequently,  inflammation. 

Opium,  by  which  we  can  effect  this  subjec- 
tion, will  ever  he  the  greatest  hoon  to  the  mili- 
tary surgeon  ;  it  is  a  remedy  which  should  never 
he  ahsent  from  his  reach,  doing  on  the  held, 
he  should  have  his  pockets  well  stored  with  it 
for  immediate  use;  and  in  the  entire  treatment 
of  the  wounded  it  will  ever  hold  a  conspicuous 
place.  Morphine  is,  perhaps,  the  hest  article  for 
wounded  men,  as  it  has  lost  in  preparation  some 
of  those  astringent  properties  which,  as  opium  or 
laudanum,  would  produce  too  great  a  tendency 
to  constipation. 

The  endermic  method  of  using  this  remedy 
would  prevent  endless  suffering  on  the  battle 
tield,  or  in  hospital  practice.  When  morphine 
is  taken  into  the  stomach,  it  b  dissolved  in  the 
fluids  there  found,  and  then  undergoes  absorp- 
tion. This  takes  place  with  greater  or  less  ra- 
pidity, according  to  the  nervous  excitement 
miller  which  the  system  is  laboring.  At  times, 
it-  absorption  is  very  slow,  and  its  effects  upon 
the  system,  from  the  small  quantity  found  in  the 
circulation,    very    indifferent.     Under    other    cir- 


>>\  RNDRKMIC    USE    OF    MOBPHIM 

cunistances,  very  large  dosei  arc  administered  in 
vain,  to  produce  the  — « » « •  1 1 » 1 1  > lt  effects  oi'  the  drug. 
h  remains,  perhaps,  unchanged  in  the  stoniackj 
whilst,  under  the  same  condition,  if  a  nnn-h 
smaller  dose,  in  solution,  be  injected  under,  the 
skin  of  anj  portion  of  the  body,  its  full  effects 
are  obtained  in  a  few  minutes.  The  following 
cases  will  show  the  marked  efficacy  of  tin-  remedy 
when  used  bypodernueally  : 

Mrs.  C.  had  been  operated  upon  for  cataract 
l>y  division  of  the  lni>.  Violent  inflammation 
ensued,  ending  in  the  destruction  of  the  eye,  and 
for  tliree  days  she  suffered  ugouj  ;  day  ami  night 
she  was  rolling  about  the  bed  in  spite  of  repeated 
doses  of  morphiue.  Finding  that  one-half  grain 
every  two  or  three  hours  produced  no  alleviation 
of  her  suffering,  1  tried  the  experiment  <<(  inject- 
iii>'"  one-third  of  a  tn*aiu  under  tin'  skin  covering 
the  sternum.  A  Wood's  eudermic  syringe  was 
used;  absorbtiou  was  immediate;  in  two  minutes 
she  was  relieved;  in  five,  all  pain  had  disappeared, 
and  in  ten  minutes  from  tlie  injection,  she  was 
sleeping  soundly  for  the  first  time  in  seventy 
hours. 

Mr.  M.  was  accidentally  shol  in  the  neck  with 
a.,  polt's  pocket  revolver.  His  head  being  turned* 
the  ball  entered  the  skin  over  the  larynx,  coursed 


KNPKRMIC  USK  OF  MORPHINE.  225 

downward  and  backward  through  the  posterior 
triangle  of  the  nock,  and  was  found  under  the 
skin  of  the  shoulder  over  the  spine  of  the  scap- 
ula, and  removed.  Considerable  swelling  and 
extravasation  followed,  which,  diffusing  itself, 
discolored  that  side  of  the  neck.  Some  of  the 
brachial  plexus  of  nerves  must  have  been  injured, 
as  the  patient  was  soon  seized  with  violent  pains, 
shooting  down  toward  the  fingers,  which,  al- 
though never  altogether  absent,  would  increase 
to  torture  as  evening  advanced.  Toward  morn- 
ing they  would  remit  and  allow  of  sleep,  after  a 
restless  and  painful  night.  Guni  opium  and 
morphine  in  Large  doses  gave  him  no  relief.  The 
arm  was  so  sensitive  that  lie  would  not  permit 
it-  being  handled.  One-fourth  of  a  grain  of  mor- 
phine, in  three  or  tour  drops  of  water,  was  in- 
jected under  the  skin  of  the  shoulder;  in  five 
minutes  all  pain  had  left  him,  and  his  arm  could 
lie  examined  rudely,  without  the  slightest  suffer- 
ing. 

Mr.  T.  had  been  suffering  with  articular  in- 
flammation of  the  righl  elbow  joint,  and  for  three 
weeks  had  suffered  so  severely  as  to  he  robbed 
ot  all  rest.  He  visited  Charleston,  tour  hundred 
miles  from  his  home,  to  seek  relict'.  An  injec- 
tion of  one-third  grain  relieved   him  of  all  pain 


'J2<»  KRMir    \'<V    OF    MOR1MM 

in  five  minutes*  After  twelve  hours  Bleep,  be 
awoke  much  refreshed;  :»n<l  although  a  general 
soreness  continued  for  some  days,  no  acute  pain 
vlt  in  the  elbow  from  the  time  of  injec- 
tion. 

By  the  use  of  tibia  little  instrument,  a  new  and 
extensive  field  for  doing  good  ifl  open  to  the  Im- 
mune military  Burgeon,  and  he  who  is  the  fortu- 
nate possessor  of  this  talisman,  will  receive  daily 
the  thanks  and  blessings  of  his  Buffering  patients, 
When  chloroform  cannot  be  obtained,  I  would 
suggest  this  mode  <»t'  blunting  sensibility,  imme- 
diately before  operations  are  performed  or  pain- 
ful and  tedious  dressings  are  made.  It  will  l»e 
found  a  good  substitute,  and  one  which  will  yield 
its  full  effects  without  delay  or  trouble.  There 
arc  very  few  injuries   requiring  operation  which 

do    not    demand    the   free    USS   of   <>]>iiim.      Xarcot- 

ising  the  patient  immediately  before  the  opera* 
tion,  and  keeping  him  under  its  influence  for 
some  hours,  is  among  the  best  means  of  prevent" 
ing  an  excess  of  reaction.  The  rapidity  of  action 
when  morphine  is  ased  endermically  is  a  very 
great  advantage  on  the  field,  where  every  moment 
is  of  value.  For  complete  narcotism,  when-  a 
sufficient  quantity  of  morphine  is  used.  ii\<-  min- 
utes  are   all    that    is   required  :    whilsl    with  ehloro- 


ENDEHMK'    USE    OF    TVTOKPTIINE.  227 

form  we  all  know  that,  when  under  excitement, 
its  inhalation  is  often  extended  to  from  thirty  to 
sixty  minutes,  ami  even  longer — time  which  the 
field  surgeon  cannot  well  spare.  Judging  from 
analogy,  I  should  say  that,  under  the  nareotising 
influence  of  morphine,  operations  should  he  much 
more  successful  than  under  chloroform  :  as  the 
impression  is  more  Lasting,  and  the  inflammatory 
sequelae  ought  to  be  in  abeyance. 


c  II  A  1'  T  E  R    V  I  . 

Complications  which  arisi  during  the  treatment  of  gun- 
shot  wounds — Erysipelas,  contagious  <nul  infectious 
character — Constant  tendency  to  debility — Treat- 
ment,  general  "ml  local — PyJbmia  "  rare  disease  in 
our  country;  symptoms — Tlf<>r>i  <>f  wafti/>li<</  ab- 
scesses—  Great  remedy;  Pretention  by  rigid  obserc- 
anci  of  hygienic  regulations — Local  and  general 
treatment — Hospital  Gangrene,  its  appearances, 
hoic  recognized;  causes  giving  rise  to  it — Thorough 
ventilation  necessary  to  successful  treatment — Local 
applications,  actual  cautery,  etc. — Tetanus,  charac- 
ters; march — Rarity  of  cure  in  military  surgery — 
Local  and  general  treatment  upon  which  most  reli- 
ance can  be  placed — Woorara  in  Tetanus — Hectic, 
from  long-continued  suppvrailnn — Pi:  km  .went  and 
Periodic  P  uns. 

Erysipelas. — We  have  already  entered,  in  de- 
tail, into  the  causes  of  secondary  hemorrhage, 
which  is  one  of  the  most  alarming  complications 

that    can     befall    tlu-   wounded.      A    second,    which 
is  eqnallj   alarming  to  both  surgeon  and  patient, 


ERYSIPELAS. 


229 


is  erysipelas.  This  disease  appears  to  revel  in  the 
depressing  influences  which  follow  armies,  and 
sometimes,  as  an  epidemic,  attacks  all  wounds, 
ravages  limbs,  and  makes  a.  frightful  list  of  vic- 
tims. For  several  years,  particularly  during  the 
winter  months,  erysipelas  lias  appeared,  at  times, 
even  as  an  epidemic  in  the  States,  especially  in  the 
middle  region  of  country.  Our  troops  can,  there- 
tore,  hardly  he  expected  to  escape  its  ravages. 
Although  it  frequently  occurs  as  an  idiopathic 
disease,  its  most  frequent  exciting  cause  is  a 
wound. 

Gunshot  wounds,  in  patients  debilitated  by 
the  many  depressing  influences  of  camp  life, 
are  peculiarly  prone  to  attacks  of  erysipelas. 
The  variety  more  frequently  met  with  among 
troops  is  the  phlegmonous,  or,  as  it  is  now 
called,  the  cellulo-eutaneous  variety.  It  makes 
its  appearance  with  violent  inflammatory  symp- 
toms, intense  swelling,  tension,  redness,  pain, 
heat,  and  effusion.  It  extends  rapidly  from  the 
wound  as  a  centre,  and  soon  covers  a  Large 
area,  accompanied  by  symptoms  of  inflamma- 
tory fever,  with  a  dirty,  foul  tongue,  and  de- 
ranged gaetro-intestinal  secretion.  It  will  he 
remarked  that  the  pulse,  although  freqaenl  and 
full,    has    no    strength,    and    general    prostration 


I'-"  KUVSI|'KI..\>. 

MWKied    :i!    ;i  wry   early  day.      Often  by    tin-   fourth 

day  the  hardened  (Bdematoua  tissue  already  feels 
boggy,  indicating  the  extensive  formation  of  pin 
and  sloughs  under  the  akin.  The  wound  usually 
gives  outlel  t<»  these  at   an   early  day. 

.\~  the  disposition  <>t"  the  disease  is  not  be 
localize  itself,  the  effusion  actively  tin-own  om  in 
the  extent  of  tissuee  undergoes  a  conversion  into 
pu»,  which  Leaves  this  matter  disseminated  in 
all  the  tissues  where  the  effusion  had  been 
poured  out.  It  is  in  this  manner  that  the  aft 
tensfre  purulent  dissection  of  limbs  takes  place; 
by  which  muscles  arc  isolated,  blood-vessela  wp- 
arated  from  the  surrounding  connections,  bones, 
exposed  from  their  periosteum,  joints  opened* 
and  a  general  destruction  of  cellular  tissue  takes 
place,  shreds,  or  layers  of  these  tissues,  re- 
sembling strips  of  wet  chamois  Leather,  may  be 
pulled  out  from  the  wound.  The  extensive  loss 
of  support  to  the  skin  causes  it  to  break  down 
into  gloughs,  which  make  a  vent  tor  the  esn 
cape  of  this   accumulating  fluid.     Nature  in   its 

weakened  condition,  cannot  stand  this  drain  of 
its  best  nutrient  material:  and  prost ration,  fce- 
ble,  irregular  pulse,  dry  tongue,  diarrhoea,  deli- 
rium, and  finally  coma,  ends  the  scene.  ()r, 
should  judicious    treatment    check    its  inroads,  a 


CONTAGIOUS    CHARACTER    OF    ERYSIPELAS.  231 

tedious  convalescence  and  a  shattered  constitu- 
tion  remain    to  the   patient. 

Erysipelas  can  always  he  recognized  by  its 
distinctive  characters  of  widely  extended  local 
inflammation,  with  tendency  to  the  rapid  sup- 
puration   and    sloughing   of    the    wound. 

The  prognosis  of  this  complication,  in  mili- 
tary surgery,  is  always  serious,  when  it  occurs 
after  gunshot  wounds,  because  the  constitutions 
of  the  patients  have  hecn  undermined,  to  a 
certain  degree,  hy  the  hardships  and  irregular- 
ities which  all  soldiers  in  time  of  war  must 
suhmit    to. 

In  the  treatment  of  gunshot  wounds  it  must 
he  rememhered  that  erysipelas,  which  is  a  very 
fatal  complication,  is  often  produced  hy  a  care- 
■  —  disregard  of  those  hygienic  regulations 
which  are  so  essential  in  the  proper  organiza- 
tion of  a  hospital.  Over-crowding,  had  ventila- 
tion, and  want  of  cleanliness,  are  constant  causes 
for  its  production  and  propagation.  As  the  dis- 
ease is  dearly  contagious  as  well  as  infectious, 
the  directors  of  military  hospitals  must  he  \'ery 
careful  how  they  permit  a  case  of  erysipelas  to 
he  Introduced  into  a  ward  with  wounded  men: 
Got  inoculation  will  at  once  ensue,  and  when 
erysipelas   has   taken   possession   of  a    ward,  it    i- 


282  CONTAGIOUS    rnARACTF.R    OF    ERY8IPE1   L8. 

with  great  difficulty  eradicated.  tts  effects  can 
be  traced  first  upon  contiguous  patients,  whose 
wounds,  healing  kindly  prior  to  the  introduc- 
tion of  this  focus  <>f  contamination,  now  lake 
<>ii  erysipelas.  The  system  soon  shows  the  ie- 
on  under  which  the  patient  is  laboring. 
Some  furthei  complication,  with  low  visceral 
inflammation  of  either  the  membranes  of  the 
brain  or  lungs  or  intestinal  surface  ensues,  and 
life  is  overwhelmed  by  this  combination. 

Erichsen,  in  liis  Science  and  An  of  Surgery, 
mentions  the  following  ease  in  proof  of  the  con- 
tagion of  erysipelas,  as  haying  occurred  in  one 
of  his  wards  at  University  College  Hospital: 
"The  hospital  had  been  \)\'r  from  any  cases 
of  this  kind  for  ;i  considerable  time,  whim,  on 
the  loth  January,  L851,  at  about  noon,  a  man 
was  admitted  under  my  care,  with  gangrenous 
erysipelas  of  the  legs,  and  placed  in  the  ward. 
On  my  visit  two  hours  after  his  admission,  I 
ordered  him  removed  to  a  separate  room,  and 
directed    the    chlorides    to    he    freely    used     in    the 

ward  from  which  he  had  been  taken.  Not- 
withstanding these  precautions,  however*  two 
days  after  this,  a  patient,  from  whom  a  portion 
of  necrosed  ilium  had  been  removed  a  tew 
weeks    previously,    and    who    was    lying    in    the 


ERYSIPELAS    A    DISEASE    OF    DEBILITY.  233 

adjoining  bed  to  that  in  which  the  patient  with 
the  erysipelas  had  been  temporarily  placed,  was 
seized  with  erysipelas,  of  which  lie  speedily 
died.  The  disease  then  spread  to'  almost  every 
case  in  the  ward,  and  proved  fatal  to  several 
patients  who  had  been  recently  operated  upon." 
If  such  be  its  tendency  in  civil  hospitals,  how 
frightful  will  its  march  be  among  the  wounded 
in  military  hospitals.  Such  cases  should  be  kept 
exclusively  to  themselves,  or  they  entail  incal- 
culable  loss  upon  the    wounded. 

The  antiphlogistic  treatment  of  erysipelas,  es- 
pecially the  phlegmonous  variety  which  we  are 
now  considering,  has  W^v  many  years  been  aban- 
doned ;  and  he  who  attempts  to  cure  erysipelas 
in  military  surgery  by  depressing  agents,  will 
pay  heavily  for  his  rashness.  However  violent 
are  its  symptoms,  the  surgeon  must  not  be  de- 
ceived. Ti  is  ,1  discus,-  qf  marked  debility:  its  vio- 
lent attack  is  only  a  mask  to  be  thrown  oft'  in 
a  few  days,  and  often  in  a  few  hours.  When 
tlu'  plan  of  attack  is  so  well  known,  as  it  is  in 
erysipelas,  where  a  study  of  the  natural  history 
of  the  disease  has  invariably  shown,  in  its  march, 
certain    and    speedy    prostration,    the    surgeon     i> 

highly  culpable    who    doea    not    commence  with 
the  earlie-t    treatment    io   build    up   and    support 


TRKATMXNT    Of    B&l  BIPXLAfl 

the  system,  ;m«l  thus  prepare  it  to  withstand  the 
depression  which  is  bo  Bure  t.»  ensae,  and  which, 
if  overlooked,  will  be  so  fatal. 

Prevention  is  always  more  judicious  khan  cure, 
and,  therefore,  oar  first  care  should  be — by  the 
stricl  observance  of  those  hygienic  regulations 
for  ventilation  and  cleanliness,  ana  against  over- 
crowding— to  keep  the  wards  of  an  hospital  with 
so  pure  an  atmosphere  as  to  give  qo  encourage- 
ment for  this  low  class  of  diseases  to  intrude 
themselves.  WTien  a  case  appears,  Isolate  it  at 
once,  and  use  every  precaution  against  contagion. 
The  sponges,  bandages,  etc.,  used  bj  such  a  pa- 
tient, should  be  confined  exclusively  to  himself; 
for  it'  the  same  sponge  !»»■  used  for  a  dozen,  they 
would  all  be  as  surely  inoculated.  Freeh  air  is 
indispensable  in  the  successful  treatment  of  this 
disease.  Leave  all  the  windows  open  for  thor- 
ough  ventilation,  running  the  risk  of  catarrhal 
affections,  which  are  trivial  when  compared  to 
the  serious  character  of  the  disease  under  dis- 
cussion. 

The  treatment,  ever  having  in  view  the  steady, 
onward  march  of  the  disease  to  suppuration, 
sloughing,  and  prostration,  unless  a  barrier  is 
thrown  across  its  path,  should  be,  from  the  com- 
mencement,   stimulating   and   supporting.      This 


TREATMENT    OF    ERYSIPELAS.  235 

tonic  course  is  prefaced  by  sonic  mild  cathartic, 
to  cleanse  the  bowels  of  impurities  which  rapidly 
accumulate  in  them,  and  excite  healthy  secre- 
tions troni  the  digestive  organs.  For  this  pur- 
pose, the  compound  eoloeynth  pill  would  be  a 
good  prescription,  although  a  dose  of  castor  oil 
or  sulphate  <)i'  magnesia,  would,  in  the  majority 
of  cases,  fill  every  indication.  <WIthout  waiting 
the  action  of  this  cathartic,  which  is  expected  to 
have  only  a  moderate  effect,  we  at  once  pre- 
scribe what  is  now  called  the  specific  by  many, 
and  recognized  as  useful  by  all,  the  tincture  of 
the  muriate  of  iron,  thirty  drops,  in  a  wineglass 
of  water,  every  three  hours.  Besides  acting  as 
a  genera]  tonic,  and  also  through  its  mineral 
acid  upon  the  liver,  promoting  the  biliary  secre- 
tion, it  aftects  directly  the  blood-vessels,  produc- 
ing contraction  in  their  walls,  and  a  diminution 
of  their  calibre,  in  this  way  relieving  congestion, 
and  preventing,  to  a  meat  extent,  effusions.  I 
have  seen  it  cut  short  a  traumatic  erysipelas  of 
the  face  after  an  extensive  operation  lor  cheilo- 
plasty.  in    thirty-six   hour.-   from   its  appearance. 

In  connection  with  the  linir.  tincture  of  iron, 
and  of  equal  importance  with  it.  is  brandy  and 
nourishment  Erichsen  says:  '"I  have  §eeu  the 
be>t    possible    results    follow    the    free    adminis- 


'J'.t'.  SUPPORTING    TRKATvr\r    NSCK86ABY. 

(ration  of  t  1 1 « -  1. randy  and  egg  mixture,  to 
which  I  am  in  the  habit  of  trusting  in  the  ma- 
jority of  these  oases."  Its  Liberal  use  will  restore 
strength,  soften  the  tongue,  and  remove  delirium. 

When  tin-  skiii  is  dry  ami  harsh,  mild  diapho- 
-  should  be  used,  and  as  anodynes  are  al- 
ways required  in  the  treatment  to  allay  pain  and 
to  give  sleep,  Dovers'  powders  would  be  a  valu- 
alilc  airent.  By  adopting  this  course  of  attend- 
ing to  the  secretions,  keeping  the  bowels  Boluble, 
and  supporting  the  system,  even  from  the  very 
commencement,  againsl  thai  prostration  which  is 
certain,  sooner  or  later,  to  show  itself,  this 
scourge  in  military  hospitals  will  be  most  suc- 
cessfully controlled. 

Considering  the  disease  as  one  of  marked  de- 
bility, most  reliam-e  should  be  placed  upon  the 
general  treatment.  All  local  applications  should 
tend  to  relieve  engorgement.  In  the  early  in- 
flammatory stage,  before  suppuration  is  estab- 
lished, painting  the  limb  with  the  per  chloride 
of  iron,  or  the  tincture  of  iodine,  or  using  com- 
presses soaked  With  tincture  of  arnica,  etc., 
would     tend     to     promote    healthy     action.       Cold 

water,   by   irrigation,  or  iced  applications,  would 
be  as  useful  here  as  in  any  other  engorgements. 

All  of  these   applications   may    be    accompanied 


V 

LOCAL    TREATMENT    OF    ERYSTT-ELAS.  237 


with  the  methodically  applied  roller,  which  will 
compress  the  limb,  and,  by  its  mechanical  sup- 
port, prevent  infiltration  and  congestion,  and  re- 
lieve tension  and  swelling.  Sugar  of  lead  lotions 
are  highly  landed.  Free  incisions  arc  recom- 
mended by  many  surgeons  to  relieve  the  en- 
gorged vessels.  They  give  great  relief  to  the 
patient,  but  it  is  a  question  whether  they  do  not 
increase  the  irritation  and  hasten  the  suppura- 
tive Stage — an  effect  not  to  he  desired,  as  the 
entire  armamentarium  of  the  surgeon  is  directed 
against  the  formation  of  pus. 

When  pus  has  formed,  which  will  he  recog- 
nized by  the  doughy  condition  of  the  parts,  into 
which  the  fingers  sink  when  pressure  is  made, 
and,  a  little  later,  by  fluctuation,  incisions,  suffi- 
ciently free  to  admit  of  the  ready  escape  of  pus, 
should  be  made,  and  stimulating  water  dressings 
continued,  to  hasten  the  elimination  of  the  sloughs 
and  diminish  the  amount  of  secretion.  The  tinct- 
ure of  arnica,  or  spirits  of  camphor,  or  Labar- 
raque's  chloride  of  soda,  diluted  with  from  six 
i<>  ten  parts  of  water,  or  diluted  tincture  of 
iodine,  make  an  excellent  stimulating  applica- 
tion. Wherever  pus  shows  a  disposition  t<>  bag, 
it  should  he  let  < >m  by  incisioas.  As  the  skin, 
largely  undermined,  is  disposed  i<>  slough  extcn- 


•J. 

sively,  it  should  be  supported  by  properly  ap- 
plied baudages,  which,  by  diminishing  the  cavity 
within,  will  prevenl  burrowing  of  pus,  and  cause 
the  skin  to  adhere  to  the  deeper  parte  as  soon 
as  adhesive  actios  can  be  excited. 

Pyjzmia,  a  disease  very  common  in  Europe, 
and  a  scourge  of  their  military  hospitals,  18  a 
disease  hut  little  known  among  us,  and,  there- 
fore, not  likely  to  attack  our  wounded,  unless  we 
neglecl  necessary  hygienic  precautions.  When 
it  -how-  itself  in  a  hospital,  like  its  kindred 
disease  erysipelas,  it  is  not  satisfied  until  it  has 
swept  oil"  its  hundreds,  and  is  a  pest  difficult  to 
be  gol  rid  of.  The  great  similarity  in  causes, 
symptoms  and  effects,  are  sufficient  grounds  for 
iating  this  with  the  large  class  of  asthenic 
diseases,  among  which  erysipelas  and  hospital 
gangrene  are  prominent.  It  is  impossible  to  con- 
trol the  symptoms  and  prevent  a  tatal  issue,  when, 
as  acute  pyaemia,  it  seizes  upon  the  wounded  in 
military  hospitals;  it  is,  therefore,  much  more  to 

be  feared  than  its  kindred  disease  JUSI  mentioned. 
Although    this    disease    is    always    associated    with 

wounds,  no  wound,  however  trivial,  or  however 
well  advanced  toward  cicatrization,  is  sale  from 
Its    attack    Until    completely    healed.      The   di>ea>e 


SYMPTOMS    OF    PYEMIA.  289 

is  supposed  to  be  caused  by  the  absorption  of 
the  ichorous  fluids  decomposing  in  the  wound, 
which  produces  a  general  poisoning  of  the  blood, 
rendering   it   unfit  for    sustaining  the   economy. 

It  lias  been  called  an  acute  decomposition  of  the 

blood. 

The  phenomena  which  accompany  tins  affec- 
tion are,  great  depression  of  the  powers  of  the 
system,  and  the  formation  of  abscesses  in  various 
parts  of  the  body.  In  the  incubative  stage,  which 
may  precede  the  explosion  of  the  disease  by 
twenty-four  or  thirty-six  hours,  the  patient  is 
restless,  anxious,  ill  at  ease,  with  forebodings  of 
impending  trouble.  He  looks  pale  and  sallow, 
has  l,.ss  of  appetite,  and  generally  deranged  se- 
cretions. The  disease  commences  by  severe 
chills,  which,  in  the  acute  cases,  are  repeated 
with  much  irregularity.  In  the  subacute  varie- 
ty, these  chills  appear  at  such  regular  intervals, 
followed  by  high  lever  and  terminating  in  pro- 
fuse sweats,  as  to  induce  the  belief  of  malarial 
fever.  In  many  cases  the  skin  is  hot,  with  a 
pungent  feel,  irrespective  of  the  chills;  in  oth- 
ers, the  chilly  ami  feverish  sensations  alternate. 
The  pulse  is  feeble:  face  pale,  with  anxiety  of 
countenance  and  tendency  to  delirium:  tongue 
foul:   a   tendency    for    sordea   to   collect    on    the 


2I<»  81MPTOM8   OP    1'V  EMI  A. 

teeth,  and  the  tongue  to  become  dry;  Btoraach 
uneasy,  with  bilious  vomiting,  and  thirst  con- 
stant. The  suspension  of  secretions  gives  a  <lull 
yellowish  icteric  tint  to  the  skin.  A.s  the  pulse 
becomes  more  :u i<  1  more  enfeebled,  the  patient 
may  complain  of  pains  in  his  joints,  Bimulaflng 
rheumatism,  and,  simultaneous  with  these,  a  red- 
dening of  the  skin,  with  swelling  •»)'  the  joints. 
Collections  of  a  purulent  character  will  soon 
after  be  detected,  distending  the  synovial  sues. 
Collections  also  occur  in  the  cellular  tissue,  and 
even  in  the  substance  <>f  organs.  These  Form 
rapidly  and  without  much  inconvenience.  Often, 
the  swelling  alone  —  which  lias  appeared  (Star- 
ing ilir  night,  unaccompanied  with  pain,  redness 

or   heat — indicates   that   a    large    collection    of  pus 

lias   alreadv    taken    place. 

Whilst  these  Bymptoms  progress,  the  wound 
usually  becomes  foul  and  Bloughy,  ceasing  to  se- 
crete pus.  This  is  not  the  invariable  rule,  as 
surgeons  have  noticed  cases  in  which  the  ap- 
pearance <>f  the  wound  was  n<>  indication  of  the 
destructive  disease  which  had  laid  its  relentless 
hand  upon  the  injured.  The  disease  may  even 
run  its  fatal  course  without  material  changes  in 
the  wound.  (Vrtain  injuries  are  more  likely  to 
he    followed    by   pyaemia,    and    those    of   hone  are 


TIIEOUY    OF    PURULENT    FORMATIONS.  S41 

said  to  be  peculiarly  exposed  to  it.  As  in  all 
such  low  diseases,  typhoid  symptoms  ensue  at 
an  early  day,  and  usually  carry  off  the  patient 
at  the  end  of  tlie  first  week.  Often  stupor  eonies 
on  as  early  as  the  fourth  day.  An  examination 
after  death  will  reveal  a  rapidly  advancing  de- 
composition, with  gas  in  the  blood-vessels,  and 
purulent  collections  in  many  organs,  as  the  Lungs, 
liver,  spleen,  kidneys,  heart  and  brain.  Similar 
collections  are.  found  in  most  of  the  large  joints, 
beside  the  multiplied  abscesses  of  the  cellular 
tissue. 

The  theory  of  the  metastatic  character  of  the 
abscesses,  or  the  sudden  change  of  place  of  such 
deposits,  by  absorption  and  redepoeit,  has  long 
been  abandoned.  Pus,  we  now  know  to  be  a 
modified  nutrient  fluid,  which,  from  an  impair- 
ment of  its  vitalizing  principle,  falls  short  of  its 
object  of  repairing  tissues.  This  exudation  leaves 
the  blood-vessels  under  ordinary  acute  inflamma- 
tion, and  is  drawn  out  by  the  excited  tissues 
which  are  not  able  to  consume  the  excess  which 
they  have  demanded  from  the  circulation.  This 
llnid,  now  ai  rest  without  the  blood-vessels,  at- 
tempts a  formation  of  it.--  own.  developing  cells 
of  this  plasma,  which  simulate  closely  the  white 
•  ells  in  tin-  progressive  development  of  the  blood. 


242  THEORY   Of    iTi:n.i:\T   FORMATIONS. 

and  are  supposed  by  Borne  pathologists  t.>  bi 
identical  with  them.  Tlii>  is  pus.  WTien  the 
entire  circulating  fluid  bas  become  poisoned,  its 
entire  plasma  or  liquor  sanguinis  is  impaired.  It 
is  from  tins  plasma  thai  the  blood-cells  are  to  be 
generated.  The  usual  process  of  development  is 
commenced,  white  cells  form  as  colorless  blood 
corpuscles,  and  when  the  continued  development 
into  the  red  or  perfect  cell  is  attempted,  many 
failures  occur.  There  are,  besides,  many  which 
had  exhausted  their  formative  powers  in  attain- 
ing the  degree  of  development  necessary  to  peiv 
feet  the  white  cell.  These  remaining  as  such. 
continue  in  the  circulation.  When  the  blood  of 
a  pyflemic  patient  is  examined,  a  very  large 
number  of  such  colorless  cells  are  found  in  the 
blood,  sufficient  to  modify  its  color,  and  it  is  in 
autopsies  that  the  separation  of  these  white  cells 
from  the  generating  fluid  shows  the  deceptive 
appearance  of  pus  in  the  blood,  or  emboli  in 
the  large  vessels  at  the  heart. 

Blood  in  this  condition,  with  an  impaired 
liquor  sanguinis,  is  unfit  for  its  duties  as  a 
life-supporting  fluid.  The  various  tissues  of 
the  body,  not  receiving  the  kind  of  nourish- 
ment appropriate1  for  their  healthy  function,  he- 
come    irritated.       Nature    tries    to    make    up    the 


IMPORTANCE    OP    HYGIENE.  243 

deficiency  in    quality  by  quantity.     The  irritated 

parts  are  supplied  witb  as  excess  of  the  im- 
paired nutritive  fluid,  which,  escaping  from  the 
capillaries,  is  received  into  the  loose  tissues. 
This  is  rapidly  converted  into  pus,  by  the  devel- 
opment of  white  or  colorless  cells  in  it,  which 
is  the  height  of  vitality  in   such   an    exudate 

Experience,  which  sustains  this  view,  shows  the 
disease  to  be  purely  a  blood  poisoning;  a  general 
disease  with  its  local  manifestations.  When  the 
blood  has  been  thus  thoroughly  deteriorated,  no 
remedy  which  art  possesses  can  restore  it  to  its 
former  healthy  condition,  and  the  patient  dies. 

Our  great  remedy  lies  in  prevention.  The  hy- 
gienic precautions  of  rigid  cleanliness,  thorough 
ventilation,  good  food,  and  proper  shelter,  with- 
out over-crowding,  will,  if  properly  insisted  upon 
by  the  medical  superintendent,  go  fur  to  keep 
away,  if  they  do  not  altogether  prevent,  the  oc- 
currence of  pyaemia.  Too  much  attention  can- 
not be  paid  to  the  detail  of  cleanliness  in  the 
ward.  The  slop  buckets,  which  are  such  a  com- 
mon nuisance,  should  be  examined  with  care, 
frequently  emptied,  scoured  daily  with  lime,  and 
always  kept  covered,  that  the  emanations  arising 

from  decomposing  urine,  which  is  very  deleteri- 
ous in   hospital  ward-,  cannot   escape:     The  bed 


24  1  IMPORTANCE    01     HYGIENE. 

and  body  linen  of  the  patients  should  be  daily 
changed,  doors  and  windows  mnsl  be  kept  open. 
[£  any  difficulty  exists  in  this  respect,  from  the 
inattention  of  nurses  or  Fears  of  patients,  it  would 
be  better  to  take  out  the  sashes  so  as  t<>  en- 
sure continued   renewal   of  the  atmosphere,  day 

and    Bight. 

There  is  a  popular  dread  of  nighl  air  which 
should  1)0  exploded.  The  purest  air  we  have  in 
cities  is  the  night  air,  and  is  the  very  article 
which  is  so  much  needed  in  hospitals.  It'  the 
patienl  is  properly  covered  in  bed,  there  is  no 
Tear  of  his  taking  cold,  or  contracting  other  in- 
jury from  the  continued  renewal  <>f  pure  air. 
These  precautions  must  nut  he  commenced  when 
pyaemia  has  already  shown  itself,  but  are  those 
necessary  to  he  taken  wherever  the  seriously 
wounded  are  treated,  or  some  low  form  of  dis- 
ease will  soon  break  out.  Any  one  who  will 
visit,  during  the  night,  a  ward  filled  with  sop- 
purating  wounds,  will  perceive  tin'  degree  of 
vitiated  air,  and  see  the  necessity  for  five  ven- 
tilation. 

It  is  a  had  principle  to  concentrate  the  seri- 
ously wounded;  always  scatter  them  over  the 
building,  mixing  them  in  with  inmates  from  other 
diseases.     This  increases  the  available  space  for 


TREATMENT    OP    PY.KMIA.  245 

the  seriously  wounded,  and  prevents  the  de- 
pressing ctlect  of  the  concentrated  emanations 
from    so   many  extensively  suppurating   wounds. 

It  is  for  a  similar  reason  that  we  have  already 
recommended  that  rooms  should  not  be  kept 
too  long  in  use  when  occupied  by  the  severely 
wounded.  As  the  air  becomes  poisoned,  the 
ward  requires  to  be  unoccupied  two  weeks  of 
every  two  months,  for  cleansing,  whitewashing 
and    purification. 

When  pviemia  threatens  to  become  general 
in  a  military  hospital,  the  seriously  wounded 
should  be  put,  if  possible,  in  tents,  or  allowed 
double  space  in  a  constantly  ventilated  room, 
and  an  additional  quantity  of  nourishing  food 
should  be  given  out  to  the  sick.  Feeding  the 
wounded  on  broths  ami  other  slops,  is  paving 
the  way  to  the  debility  which  is  a  precursor  of 
pyfemia.  All  small  operations  should  be  avoid- 
ed, and  even  the  nasty  opening  of  abscesses 
guarded  against.  The  best  protection  against 
this  disease   is  a   whole   skin. 

When  the  acute  form  of  the  disease  shows 
itself,  surgery  can  do  but  little  to  assist  the 
patient  If  it  be  possible,  more  benefit  will  be 
derived  from  changing  the  patient  into  fresh  air 
than  from  any  other  remedy.     Our  entire  reliance 


2  I   I  TKKATMI \ l     01    l'V  i:MI.\. 

should  be  placed  apon  the  stimulating  tonics. 
Strong,  nutritious,  easily  digested  food,  and  opium 
to  allay  pain  and  restlessness,  are  the  means  re- 
quired. The  tendency  to  delirium  should  not 
prevent  the  free  use  of  this  last  remedy,  for 
although  it  would  increase  the  difficulty  if  it  be 
given  in  inflammation  of  the  brain  or  meninges, 
it  allays  pain,  removes  restlessness,  stops  mut- 
tering, and  induces  quiet  Bleep,  when  given  in 
cases  of  debility  accompanied  by  delirium.  As 
in  erysipelas,  the  arid  preparations  of  iron,  as  a 
blood  tonic,  may  be  administered. 

Although  bo  little  is  to  be  expected  in  the 
acute  form  of  Mood  poisoning,  in  the  subacute 
or  chronic  pyaemia,  much  benefit  will  be  derived 
from  rigidly  pursuing  the  course  of  treatment 
just  marked  out.  By  the  stimulating  and  sap- 
porting  plan,  with  change  of  air,  many  patients, 
after  a  long  struggle,  may  be  saved. 

The  important  indication  for  local  treatment 
in  pyaemia  is  to  prevent  the  accumulation  of  pu- 
trescent fluids  in  the  wound  by  cleanliness — and 
tin-  frequent  application  of  chlorinated  washes, 
which  also  remove  factor  and  Btimuhtte  the  granu- 
lating surface.     The  abscesses  which  form  during 

the     march     of    the    disease,    should     not      he    too 


HOSPITAL   GANGRENE.  247 

fegstily  opened,  as  this  course,  pursued  with  the 
many   collections,   will   induce    rapid  prostration. 

Hospital  Gangrene. — Still  another  fatal  com- 
plication, to  which  gunshot  wounds  arc  liable, 
is   hospital  gangrene,   the    name    being   significant 

of _  the  cause  of  this  pest,  as  it  is  never  seen  as 
an  isolated  disease  without  the  crowded  wards 
of  a  hospital.  It  is  highly  probable  that,  like 
the  former  diseases  which  we  have  jnst  con- 
sidered, it.  is  a  blood  poisoning,  depending  upon 
a  foul,  infected  atmosphere,  operating  upon  a 
depraved  and  enfeebled  constitution.  It  seldom 
attacks  the  strong  and  robust,  but  most  fre- 
quently those  who  have  become  debilitated  by 
exposure,  disease,  want  of  proper  food,  intern" 
perance,  etc.;  so  that  in  a  crowded  hospital, 
when  gangrene  threatens  to  devastate  the  wards, 
you  might  select,  in  advance,  the  cases  which 
will  most  probably  be  first  attacked.  Many  sur- 
geons consider  it  a  constitutional  disease,  occur- 
ring from  a  strictly  local  cause,  which  is  found 
within  the  walls  of  the  hospital.  All  surgeons 
recognize  its  contagions  as  well  as  infections 
character,  and  the  facility  of  transmitting  it  by 
sponges  or  dressings  used  in  common  in  a  ward. 
The   facility   with    which    the   air  of  a  ward,   or 


248  CONTAGION    OP    HOSPITAl 

evea  of  a  hospital,  becomes  impregnated  with  this 

poison,  \\<»iil<l  BhoW  that  animal  exhalation-,  es- 
pecially from  those  suffering  under  this  dis< 
possess  the  power  of  diffusing  it.  Burgmati  re- 
ports, that  hospital  gangrene  prevailed  in  one 
of  the  low  wards  at  Leyden,  wliilst  the  ward  or 
garrel  above  it  was  free.  The  Burgeon  mads 
an  opening  in  the  ceiling  between  the  two,  in 
order  to  ventilate  the  lower  or  affected  ward, 
and  in  thirty  hours  three  patients  in  the  upper, 
room,   who  lay   uexl   the  opening,  were  attacked 

by    the    disease,    which    soon    spread    through    the 
whole   ward. 

Guthrie  confirms  the  above  by  his  experience* 
which,  he  Bays,  left  no  doubl  upon  the  mind  o[' 
any  one  who  had  frequent  opportunities  of  see- 
ing  the  disease,  that  one  case  of  hospital  gan- 
grene was  capable  of  infecting  not  only  every 
ulcer  iii  the  ward,  hut  in  every  ward  near  it, 
and  ultimately  throughout  the  hospital,  however 
extensive  it    may   he. 

Both  English  and  French  Burgeons,  in  the  Cri- 
mean Avar,  recognised  the  atmosphere  as  clearly 
the  vehicle  of  its  extension,  and  that  its  increase 
or  diminution  depended  upon  the  crowded  con- 
dition of  the  wards  and  tin-  degree  of  ventila- 
tion.     They,    also,    observed    the   certainty   with 


SYMPTOMS    OF    TTOSPT1AT,    GANGRENE.  249 

which  it  increased  when  the  same  sponges  were 
use*!  for  gangrenosa  and  healthy  wounds.  It  may 
be  considered  a  thoroughly  contagious  disease. 

Those  who  observe  the  march  of  the  healing 
process  id'  wounds,  within  and  without  hospitals, 
knew  how  easily  the  one  is  cured,  and  with 
what  difficulty  a  tedious  cure  is  obtained  in  the 
other.  Where  the  exhalations  from  many  sup- 
purating wounds  are  concentrated  in  a  ward, 
the  cicatrization  of  all  wounds,  even  the  most 
simple,  are  retarded,  and  contagion  of  any  kind 
readily  propagated. 

///  military  hospitals,  tl«'  hospital  gangrene  n'iU  he 
recognized  by  ^<c  following  appearances:  Although 
the  patient  may  have  recently  shown  feverish 
symptoms,  with  loss  of  appetite,  yellowish  or  pale 
skin,  dirty  tongue,  and  deranged  bowels,  the 
first  appearance  of  the  disease  is  recognized  in 
the  changes  which  the  wound  undergoes,  which 
has  led  many  to  believe  it  to  be,  at  first,  ;i  local 
disease,  in  time  infecting  the  system.  The  gran- 
ulating surface  of  a  healthy  sore,  about  taking 
un  this  sloughing  condition,  becomes  dry  and 
painful.      The    florid    hue    of    the    granulations 

rapidly  disappears,  and  is  replaced  by  a  dirty 
u-ray  or  ash-colored  slough,  which  fills  the  wound 
and   forms  a   pultaceous   and   adherent   covering 


L'.'iit  SYMPTOMS   OS    BOSPITAX   SANOMNK. 

to  the  granulating  surface.  As  this  gray  slough 
increases  in  extent  and  depth,  the  surrounding 
surface  becomes  oedematous,  swollen,  and  of  a 
livid  red  or  purplish  color.  This  engorged  ap- 
pearance  of  the  contiguous  >kin  always  precedes 
the  advance  of  the  gray  slough.  The  edg< 
the  nicer  arc  abruptly  cut,  undermined  and 
everted,  gradually  assuming  a  circular  outline, 
irrespective  of  the  form  of  the  wound  prior  to 
its  invasion.  The  gray,  tenacious  mass,  being 
formed  of  the  mortified  tissue,  holds  its  place 
and  cannot  be  wiped  oil',  although  it  sways  to 
and  fro  when  any  attempt  is  made  to  cleanse 
the  wound. 

The  Liquefaction  of  these  mortified  tissues  soon 
commences,  and  a  dirty,  thick,  highly  offensive, 
irritating  fluid,  produced  from  the  putrefaction 
of  the  slough,  escapes  from  the  wound,  diffusing 
a  peculiar  odor  which,  when  once  smelt,  will 
always  he  recognized.  This  is  the  poison  which 
possesses  such  powers  of  infection  when  brought 

in    contact    with    healthy    wounds. 

(Mice     the     disease    lias    fairly    rooted    itself,    its 

ravages  are  extensive  and  rapid.    One  can  nearly 

>ce  the  extending  line  of  slough,  and  often  in 
twenty-four  hours  large  portions  of  the  skin, 
cellular  tissue,  and    muscles  will  have  mortified. 


SVMI'TOMS    OF    HOSPITAL    GANGRENK.  251 

These  changes  in  the  wound  are  accompanied 
by  a  severe   burning,  stinging,  lancinating    pain. 

Pari  passu  with  tins  local  destruction,  the  sys- 
tem is  gradually  or  rapidly  showing  the  influ- 
ence •  of  the  poison.  Although  the  symptoms 
may  he  at  first  of  an  inflammatory  character, 
accompanied  by  a  high  fever,  the  pulse  soon 
loses  its  strength,  the  mind  is  peevish,  fretful 
and  desponding,  and  the  tongue  becomes  dry  and 
brown.  The  pain  accompanying  these  changes 
is  so  severe  as  to  deprive  the  patient  of  sleep. 
As  the  febrile  accompaniments  of  the  disease 
rapidly  assume  a  typhoid  cast,  delirium  ensues, 
and,  with  a  tendency  to  coma,  becomes  a  promi- 
nent symptom. 

Should  the  case  not  terminate  before  the  elim- 
ination of  the  sloughs  commences,  the  separa- 
tion of  these  may  open  large  vessels,  from  which 
the  hemorrhage  will  rapidly  destroy  life.  The 
great  nerves  and  arteries  appear  to  resist  the 
gangrenous  destruction  longer  than  the  muscu- 
lar or  cutaneous  structures.  These  yield  in  the 
end,   and    repeated    hemorrhages  close   the   scene. 

J  witnessed  an  epidemic  of  hospital  gangrene, 
in  Milan,  during  the  summer  ^\'  L859.  A  large 
number  of  Austrian  wounded  had  been  put  in 
a    barrack   prepared    for  their  reception.      They 


_•>_  SYMPTOMS    OF    B08PITAL    QANGRENK. 

had  undergone  many  hardships,  retreating  daily 
before  a  victorious  enemy,  and  had,  prior  to  the 
battle  of  Solferino,  tasted  no  food  for  forty- 
eight  hours.  They  had  been  deceived  by  their 
Leaders,  who  had  taught  them  that  certain  death 

awaited  them  should  they  tall  into  the  hands  of 
the  Italians.  With  these  impressidns,  the  wound- 
ed hid  themselves  in  the  ditches  and  undeiorush 
of  the  extended  battle  field,  where  many  per- 
ished. Some  were  not  discovered  for  two  or 
three  days,  when  they  were  sent  to  the  hospi- 
tals. The  previous  hardships  which  the  A.ustri- 
ans  had  undergone,  their  Lymphatic  tendencies, 
their  irregular  living,  with  the  moral  depression 
of  repeated  defeat,  exposed  them  to  the  ravages 
of  the  lowest  forms  of  disease.  Eospital  gan- 
grene  raged  fearfully  among  them,  destroying 
numbers.  Many  of  their  wounds  were  frightful 
from  the  extended  Bloughing,  and  their  worn 
frames  and  gaunt  visages  indicated  a  fearful 
combat  with  disease.  I  was  particularly  struck 
with  the  mental  depression  under  which  many 
of  them  were  suffering — amounting  to  despond- 
ency. This  was  further  increased  by  the  atten- 
dants and  surgeons  not  Bpeaking  the  Ghsrmah 
language,  so  that  neither  could  their  wants  lie 
known   nor  could  sympathy  he  extended  to  them. 


SYMPTOMS    OF    HOSPITAL    GANGRENE.  253 

From  the  combination  of  these  depressing  causes, 
an  epidemic  of  sloughing  phagadosna  appeared, 
which  was  appalling  even  to  those  accustomed 
to  see  disease  in  its  most  fearful  form. 

McLeod  tells  us  that,  iii  the  Crimea,  during 
the  heat  of  the  summer  of  1855,  not  a  few  of 
those  operated  upon  were  lost  by  a  gangrene 
of  a  most  rapid  and  fatal  form.  All  of  those 
attacked  by  it  were  carried  off.  In  the  ease  of 
a  few,  who  lived  long  enough  for  the  full  de- 
velopment of  the  disease,  gangrene  in  its  mosd 
marked  features  became  established;  but  most 
of  them  expired  previous  to  any  sphacelus  of 
the  part,  overwhelmed  by  the  violent  poison 
which  seemed  to  pervade  and  destroy  the  whole 
economy.  "The  cases  of  all  those  who  died  in 
my  wards  seemed  to  be  doing  perfectly  well  up 
to  sixteen  hours,  at  the  furthest,  before  death. 
During  the  night  previous  to  death,  the  patient 
was  restless,  but  did  not  complain  of  any  par- 
ticular uneasiness.  At  the  morning  visit,  the 
expression  seemed  unaccountably  anxious,  and 
the  pulse  very  slightly  raised,  the  skin  moist, 
and  the  tongue  clean.  By  this  time  the  stump 
felt,  as  the  patient  expressed  it.  heavy,  like  lead, 
and   a  burning,   stinging  pain   had   begun    to    shool 

through    it.       <  >n    removing    the    dressing,    the 


254  THKAIMKNT    01    HOSPITAL    ■. A  M.U1  N  I 

stamp  waa  found  slightly  swollen  and  hard,  and 
the  discharges  thin  and  gleety,  colored  with 
blood,  and  having  masses  of  matter,  like  gruel, 
uonally  mixed  with  it.  A  few  hours  afteis 
ward,  the  limb  would  be  greatly  Bwollen,  the 
skin  tense  and  white  and  marked  along  its  sur- 
face by  prominent  bine  reins.  The  cut  edges 
of  the  stump  looked  tike  pork.  Acute  pain  was 
felt.  The  constitution  by  this  time  had  begun 
to  sympathize.  A  cold  sweat  covered  the  body* 
the  stomach  was  irritable,  and  the  pulse  weak 
and  frequent.  The  respiration  became  short  and 
hurried,  giving  evidence  of  tin'  great  oppression 
of  which  the  patient  so  much  complained.  The 
heart's   action  gradually   ami   surely  go(   weaker, 

till,  from    fourteen    to   sixteen  hours   from   the  first 
Itad  symptom,   death    relieved   his  sufferings." 

In  the  treatment  <>/  hospital  gangrene,  we  must 
consider  it  frequently  a  local  disease,  with  rapid 
tendency  to  constitutional  poisoning.  One  of  our 
early  duties  would  be  to  destroy  the  accumulat- 
ing poisonous  ichor  in  the  wound  to  prevent 
further  infection,  whilst,  at  the  same  time,  we 
correct  those  depressing  causes  which  predisposed 
to  the  disease,  Guthrie  says,  that  constitutional 
treatment,  and  every  kind  of  simple,  mild,  deter- 
gent  applications,  always   failed    unless  accoiiipan- 


TREATMENT    OF    nOSPITAL    GANGRENE.  255 

ied  by  absolute  separation,  the  utmost  possible 
extent  of  ventilation,  and  the  greatest  possible 
attention  to  cleanliness:  and  not  even  then  with- 
out great  loss  of  tissue  in  many  instances. 

The  local  remedies  act  as  caustics,  and  com- 
pose the  most  energetic  of  the  pharmacopoeia. 
The  French  and  German  military  surgeons  pre- 
fer the  actual  cautery  to  all  other  applications 
to  check  the  encroachments  of  the  disease,  al- 
though Armaml  even  speaks  of  this  remedy,  upon 
which  much  reliance  was  placed,  as  exception- 
ally checking  tlie  progress  of  mortification.  "Af- 
ter a  thorough  cauterization,  the  eschar  separates 
rapidly,  and  often  exposes  a  second  infected  sur- 
face ol'  greater  extent."'  His  individual  experi- 
ence gives  the  preference  to  tincture  of  iodine 
as  a  local  application.  The  best  results  were 
obtained  when  a  compress  saturated  witli  it  was 
applied  to  the  wound.  Guthrie  recommends  the 
liberal  use  of  the  concentrated  mineral  acids,  es- 
pecially the  fuming  nitric  acid.  McLeod  refers 
to  the  nitric  acid  :is  the  most  efficacious  means 
ct'  stopping  the  sloughing  process.  Labarraque's 
chloride  of  soda,  pyroligneous  acid,  creasote.  peT 
chloride  of  iron,  lemon  juice,  etc..  are  frequently 
nsed  with  benefit  :  but  general  experience  in  mil- 
itary surgery  givei  the  preference  to  the  mineral 


•J.V.  TRK\i\!i:vr   01   BOSP1TAL  I  \  VI 1 1;  i.sr. 

acid  preparations.  These  are  to  be  followed  by 
irrigation,  which  washes  away  the  ichorous  dis- 
charges as  rapidly  as  they  form,  and  prevents 
further  infection.  Powdered  charcoal,  camphor, 
and  bark  poultices,  are  useful  applications. 

The  Local  treatment  alone,  without  the  consti- 
tuti6nal,  would  be  followed  by  no  good  results. 
']'!■<  most  important  of  all  //><  constitutional  remedies 
is  charuji  of  air.  W  the  patient  could  be  removed 
from  the  atmospheric  influences  of  the  infected 
ward.  Lis  chances  for  recovery  would  be  greatly 
increased.  Baudens  states  that  without  isolation 
all  treatment  will  Bhow  itselt  powerless.  Carry- 
ing ilif  patient  from  the  ward  to  a  tenl  would 
be  followed  by  immediate  amelioration — fresh  air 
being  the  great  remedy.  Keeping  the  intestinal 
action  free  by  a  little  Mtu-  mass,  or  compound 
extract  of  colocynth,  and  the  liberal  use  of  tonics 
and  stimulating  diet,  with  wine  or  brandy  and 
opium,  will  complete  the  treatment. 

Opium  is  required  in  every  stage  of  the  dis- 
and  is  administered  in  large  and  repeated 
a  to  allay  tin-  pain,  irritability  and  sleep- 
lessness, which  so  generally  attend  the  severe 
cases  oi  gangrene.  The  diet  t^hroughoul  Bhould 
lie  highly  nutritious,  and  should  be  liberally  pre- 
scribed.    McLeod,  in  Id.--  experience  in  the  Eng- 


TREATMENT  OF  HOSPITAL  GANGRENE.      2f)7 

lish  service,  states  "  that  nitric  acid,  applied  lo- 
cally, and  the  exhibition  of  the  tincture  of  the 
muriate  of  iron  internally  in  half  drachm  doses, 
three  times  a  day,  proved  to  be  the  most  effica- 
cious means  of  stopping  it,  as  it  appeared  in  our 
hospitals." 

It  is  thus  seen  that  the  three  most  fatal  com- 
plications to  gunshot  wounds  are  the  three  kin- 
dred diseases,  erysipelas,  pyaemia,  and  hospital 
gangrene,  all  recognizing  a  common  origin,  viz: 
imperfect  ventilation  and  want  of  proper  atten- 
tion to  cleanliness,  with  the  absence  of  those. 
hygienic  regulations  necessary  for  the  health  of 
an  army. 

\Yith  propel-  care  from  the  medical  corps,  these 
diseases,  which  are  the  chief  scourges  to  the 
wounded,  and  the  causes  of  nearly  all  the  deaths, 
can  be  in  a  measure,  if  not  altogether,  prevented. 

Once  they  have  made  their  appearance  in  a 
hospital,  they  will  never  be  got  rid  of  until  the 
building  is  closed,  and  the  proper  measures  for 
purification  resorted  to.  Prevention,  in  this  in- 
stance as  in  all  others,  will  be  found  better  than 
attempts   ;i1    cure,  as  many  of  these   diseases,  once 

they  appear,  are  quite   unmanageable,   and   tend 

naturally  to  a  fatal  issue.  All  of  these  diseases 
are  benefited  by  the  isolation  of  the  patient  in  :i 


258  TKTAM  B. 

pare  atmosphere,  when  the  infectious  character 
of  the  disease  ia  counteracted,  and  1 1 1  *  -  patient  is 
in  the  besl  condition  For  successful  treatment.  In 
all  of  them  the  antiphlogistic  treatment  cannot 
be  too  severely  condemned.  However  doubtful 
Buch  :i  course  may  be  in  a  civil  hospital,  or  in 
private  practice,  with  patients  unexposed  to  hard- 
ships, who  are  robust,  and  have  not  been  influ- 
enced by  depressing  agents,  in  a  military  hospital, 
with  the  material  which  compose  the  inmates,  an 
antiphlogistic  course  should  not  be  thought  o£ 
Tin'  supporting  plan,  with  stimulating  tonics,  is 
the  only  rational  course  that  promises  su< 
and  should  be  followed  throughout  the  treatment. 
Attending  to  the  Becretiona  with  mild  remedies, 
allaying  pain,  and  inducing  refreshing  sleep  l>y 
means  of  opium,  good  diet,  and  due  regard  to 
hygienic  regulations,  will  be  the  course  of  prac- 
tice to  be  pursued. 

Tetanus.  —  Another  fatal  complication  of 
wounds,  depending,  however,  apon  very  differ- 
ent circumstances  from  those  recently  consid- 
ered, is  tetanus,  or  lockjaw  —  a  disease  fearfully 
malignant  Qnder  any  circumstances,  and  with 
scarcely  an  exception  in  military  Burgery.  For- 
tunately,   this    is    never    an    epidemic,   nor  can    it 


TETANUS.  259 

infect  a  hospital,  although  pathologists  have 
recently  attempted   to  prove  its  origit)  traceable 

to  an  animal  poison.  This  disease  is  much 
more  frequent  with  ua  than  it  is  in  Europe, 
where  it  is  rarely  met  with.  In  the  Crimean 
service,  MeLeod  mentions  but  thirteen  eases  as 
occuring  in   camp  and  in   the  hospitals. 

This  disease,  which  does  not  depend  upon  the 
size  of  the  wound  from  which  the  patient  is 
suffering,  appears  to  he  caused  frequently  by 
sudden  atmospheric  changes  in  connection  with 
dampness.  Larrey,  in  his  experience  hoth  in 
Germany  and  Egypt,  found  it  in  those  wounded 
who,  after  sustaining  great  exertions  during  the 
fight  on  a  very  hot  day,  were  exposed  to  the 
cold,  damp  night  air  on  the  field,  without  shel- 
ter. Alter  the  battle  of  Bautzen,  where  the 
wounded  were  left  on  the  field  during  the  night, 
exposed  to  severe  cold,  Larrey  found  on  the  fol- 
lowing morning  that  more  than  one  hundred 
were  affected  by  tetanus.  In  very  hot  climatei 
it  requires  hut  little  excitement  to  produce  it — 
a  trifling  puncture  or  scratch  is  at  times  sutH- 
cienl  to  cause  an  attack,  and  it  has  been  noticed 
by  military  surgeons  that  the  scraping  of  the 
skin  by  a  hall,  with  bruising  of  the  nerves,  is 
more  liahle  to  this  complication  than  the  more 
severe  wound-  • 


260  causi  a  o*  rv\  am •-. 

The  proximate  cause  appears  to  be  Bome  in- 
jury to  tin-  nerves,  ool  necessarily  connected 
with  an  open  wound,  as  it  haa  been  known  to 
follow  the  blow  of  n  whip  or  a  spraiu.  Wounds, 
in  certain  situations,  are  thoughl  t<>  favor  its  ap- 
pearance, viz :  injury  td  the  hands,  feet,  joints. 
etc.  It  may  occur  very  Bpeedily — a  few  hours 
after  the  injury  has  been  received,  or  it  may  pot 
occur  For  days.  Rarely  does  it  attack  chronic 
wound-  after  the  twentieth  day:  [ts  common 
period  for  appearing  is  between  the  lii'tli  and 
fifteenth  day,  when,  perhaps,  the  simple  wound 
haa  completely  cicatrized.  The  premonition  of 
uneasiness  on  the  pari  of  the  patient,  with  vague 
fears  of  impending   trouble,  disturbed  digestion, 

etc,    are    nol    often    observed. 

The  first  symptom  which  we  usually  recognize 
is  a  complaint  of  soreness  of  the  throat,  which, 
in   ordinary  cases   precedes,   by  some   hours,  the 

contraction  of  the  muscles  6f  the  jaw  and  pinch- 
in-'  of  the  features.  The  spasm,  instead  of  com- 
mencing in  the  injured  part,  always  -hows  itself 
lirst    in    those   muscles   supplied    by    the    fifth    pair 

of  nerves;  and  although   in   sudden  and  violent 
the   spasmodic  contraction  of  the  muscles 

generally  may  rapidly  follow  the  locking  of  the 
jaw.-,   or  appear  to   be  even   simultaneous  with  it. 


SYMPTOMS    OF    TETANUS.  261 

they  are  never  found  to  precede  it.  The  locking 
of  the  jaws;  the  contraction  of  the  muscles  of 
the  neck,  especially  the  sterno-cleido-mastoid, 
which,  by  bounding  under  the  skin,  accurately 
defines  the  triangles  of  the  neck  ;  the  hardened 
condition  of  the  abdominal  muscles,  the  knots 
formed  over  the  region  o\'  the  recti  muscles  dur- 
ing the  paroxysm;  the  stiffening  of  the  muscles 
of  the  legs,  whilst  those  (A'  the  arms  remain 
free  ;  the  sardonic  expression  of  the  face  ;  clear 
brain;  sleeplessness:  profuse  sweating;  incessant 
desire  to  drink,  and  difficulty  in  accomplishing 
i)  ;  the  occurrence  of  paroxysms  of  violent  mus- 
cular contraction  every  few  minutes,  with  loss  of 
strength  in  the  pulse,  and  rapid  prostration,  de- 
tine  the  disease  so  accurately  that  it  becomes 
one  of  those  most  easily  recognized. 

Any  one  who  has  ever  felt  a  cramp  of  the  calf 
muscles,  may  have  a  faint  appreciation  of  the 
intense  pain  which  a  permanent  and  violent 
cramp  of  all  the  muscles  must  produce — a  pain 
sufficient  to  destroy  life  promptly,  through  ner- 
vous exhaustion. 

The  prognosis  of  this  disease  is  so  serious, 
and  the  treatment,  however  conducted,  so  unsat- 
i  factory,  thai  many  surgeons  of  large  experi- 
ence   have     never    cured     a     ease     of    traumatic 


262  IIM'.ATMKNT    01    TKTAM    S. 

tetanus.  That  fruitful  source  of  information, 
pathology,  gives  as  no  instruction  iu  this  dis- 
ease. An  autopsy  reveals  nothing  commensusata 
with  ill*-  intensity  of  symptoms.  A  alight  eon- 
■  m  m)'  the  spinal  eord  and  medulla  oblon- 
gata, is  all  thai  can  be  discerned.  From  the 
symptoms,  we  judge  of  the  disease  as  one  of 
intense  nervous  irritation.  Recognizing  the  ex- 
haustion which  so  soon  >lio\\s  itself,  the  treat- 
ment as  laid  down  by  the  most  recent  authors, 
and  the  <>nc  now  generally  adopted,  is  one  of 
support  to  both  the  nervous  and  muscular  sys- 
tems. 

Larrey  has  cut  short  the  disease  in  its  inci- 
pient stage  by  amputating  the  limb,  or  dividing 
the  nerve  which  is  supposed  to  he  at  fault. 
Other  surgeons,  by  isolating  the  irritation,  have 
been  equally  successful.  Such  results  are.  how- 
ever, rarities  in  practice,  the  operation  often 
tailing  when  performed  at  the  very  commence- 
ment of  the  symptoms,  and  always  when  the 
disease  shows  confirmed  general  spasms.  At 
times,  patients  Buffering  from  tetanus  get  well 
under  the  most  varied  treatment.  Nearly  every 
powerful  remedy  in  the  pharmacopoeia  has  been 
recommended  as  a  sovereign  cure  hv  those  who 
mav  have  derived  some   benefit   from  such  in  the 


TREATMENT  OF  TETANUS.  263 

treatment  of  tetanus.  Disappointment  is  sure  to 
follow  the  confidence  placed  in  any  of  these  arti- 
cles. The  most  judicious  course  is  to  disclaim 
all  specific  remedies,  and  be  guided  by  the  symp- 
toms; allay,  if  possible,  the  intense  nervous  ex- 
citement, and  the  local  cause  of  irritation  by 
which  the  disease  is  occasioned,  and  support  the 
system  against  the  ensuing  exhaustion,  both  by 
sustaining  the  patient's  strength  by  strong,  easily 
digested  food,  and,  by  procuring  sleep,  to  allow 
the  nervous  system  the  opportunity  of  regaining 
its  wasted  powers. 

The  local  treatment  should  consist  in  examin- 
ing the  wound  for  foreign  bodies,  and  removing 
them,  if  possible,  as  they  are  frequently  the  ex- 
citing cause  of  nervous  irritation,  under  the  pre- 
sumption that  unless  the  local  cause  be  removed 
we  can  expect  but  little  abatement  of  the  general 
tetanic  excitement.  Should  no  foreign  body  be 
found,  if  it  be  possible,  an  incision  may  be  made 
on  the  cardiac  side  of  the  wound,  to  divide  the 
nerves  implicated,  and  paralyze  their  sensibility. 
The  powerful  acids  and  the  actual  cautery  have 
been  recommended  for  the  similar  purpose  of 
destroying  the  excited  nerves  at  (lie  seat  of 
injury;  and  although  they  may  be  at  times 
d,  T  have   seen    fatal    tetanus  occur  in  ulcers 


'-'til  TKKATMKNT    OF    TKTAM   - 

under  the  cauterizing  treatment,  and  I  have  re- 
cently lost  a  ease,  after  amputation  of  the  leg, 
from  gunshot  fracture  of  the  tibia,  in  which  mor- 
tification attacked  the  stump.  After  arresting 
the  slougTfing  by  the  liberal  use  of  Fuming  nitric 
acid,  and  having  a  line  of  demarcation  estab- 
lished, tetanic  symptoms  appeared  and  destroyed 
the  patient  in  thirty-six  hours.  A  solution  of 
morphine,  atropine  or  kindred  preparations,  may 
be  instilled  into  the  wound,  for  their  sedative 
action,  and  the  simple  water  dressing  continued. 

If  it  be  a  small  member  wounded,  such  as  a 
finger  or  toe,  an  early  amputation  may  stop  the 
spasm  by  removing  the  irritating  cause..  This 
amputation  should  be  performed  irrespective  of 
the  local  condition  of  the  wound.  Should  the 
injured  extremity  be  in  a  sloughy  slate,  so  as  to 
render  its  recovery  doubtful,  amputation  should 
be  performed  at  any  stage  of  the  disease.  When 
tetanus  supervenes  upon  an  amputation,  it  would 
he  better  to  perform  a  second  amputation  upon 
the  early  establishment  of  the  symptoms,  as  good 
results  mighl    follow  such   a  course. 

The  constitutional  treatment  will  have  for  its 
object  to  remove  all  general  and  internal  causes 
which  may  keep  up  excitement.  We  should  con- 
stantly bear  in  mind  th<<t  tetanus  is  cm   affection   oj 


TREATMENT   OF   TETANUS.  2(55 

debility,  and  that  the  violence  of  the  spasmodic 
paroxysm  gives  a  false  appearance  of  strength 
to  tin1  patient,  whilst  the  principal  source  of 
danger  and  death  is  from  fatigue,  induced  by 
the  energy  of  the  muscular  movements  and  the 
consequent  want  of  rest. 

In  hospital  practice,  remove  the  patient  at 
once  to  a  small  room  or  tent  where  he  will  be 
alone  with  his  single  attendant.  As  the  bowels 
are  always  constipated  and  loaded  with  offensive 
feral  collections,  which  might  assist  in  sustain- 
ing the  excitement  of  the  nervous  system,  they 
should  be  at  once  emptied  by  a  large  dose  of 
calomel,  with  gamboge,  aloes,  or  scammony. 
When  a  difficulty  is  found  in  administering  this, 
from  the  locked  condition  of  the  jaw,  one  or 
two  drops  of  croton  oil  can  be  placed  within 
the  teeth,  when,  mingling  with  the  saliva,  it 
will  be  swallowed.  Three  or  four  times  the 
ordinary  dose  will  he  required  to  relieve  the 
torpid  bowels.  The  patient  should  then  be  kept 
perfectly  quiet — if  possible,  by  himself,  as  the 
Btirring  about  of  persons,  noises,  draughts,  etc., 
excite  sudden  and  repeated  paroxysms  of  spasm, 
bladders,  blisters,  or  chloroform  applications, 

may   be   made    to    the    upper  portion   of  the   spine 
to  allay,   it  possible,  the  irritation  of  this   region. 


•Jl'.i'.  I  Kl.ATMKNT    01    TBI   Wl   - 

Although  opium  is  universally  administered  as 
an   intenft   sedative,    it  are    not    often 

obtained  even  when  given  in  large  doses.  It 
is  believed  that  it  often  remains  unabsorbed  in 
the  .-toinacli.  and,  therefore,  without  action.  The 
same  of  conium,  hyoscyamus,  and  the  entire  class 
.  when  given  in  the  form  of  pill  or 
extract.  Unless  mediciues  arc  irhen  dissolved, 
they  are  not    likely  to  be  absorbed,  or   they  are 

taken    U]t    BO    slowly    that     their    good    effects    arc 

not  perceived. 

Recently,  in  two  cases  of  traumatic  tetanus, 
I  have  tried  the  hypodermic  administration  of 
morphine  in  one-third  graiu  doses,  dissolved  in  a 
few  drops  of  water,  and  injected  by  means  of 
a  Wood's  syringe.  The  effecl  of  the  remedy  in 
a  few  minutes  was  decided,  hut  was  not  persist- 
ent; partial  relaxation  of  the  jaws  could  always 
be  effected,  so  that  nourishment  might  be  taken, 
and  sleep  could,  also,  be  induced.  It  is  by  far 
the  preferable  mode  of  using  opium.  a>  its  offects 
can  1"'  speedily  and  with  certainty  obtained. 
In  one  case,  in  which  I  injected  one-tenth  grain 
of  atropine  under  the  skin  of  the  arm.  the  effect 
upon  the  pulse  vgas  so  immediate  that,  in  five 
minute-,    it    had    increased    from    eighty    to    one 

hundred    and    fifty    heats.       It     rapidly    all'eeled    (he 


TREATMENT  01  TETANUS.  267 

salivary  and  mucous  glands  of  the  mouth  — 
diminishing  their  secretions,  without,  however, 
producing  dilatation  of  the  pupils  or  causing  re- 
laxation of  the  muscles.  As  no  beneficial  effect 
followed  tne  atropine  injection,  morphine  had  to 
be  used,  when  relaxation  to  a  certain  extent  was 
immediately  obtained. 

The  libera]  use  of  belladonna  has  been  recom- 
mended, and,  from  its  great  utility  in  relieving 
congestions  of  the  lower  portion  of  the  spinal 
cord,  we  might  naturally  infer  similar  good  effects 
for  the  medulla  oblongata.  The  tincture  of 
cannabis  indica  has  been  highly  extolled.  Some 
i lasea  have  recovered  under  its  use.  hut  a  very 
much  larger  number  have  died  in  spite  of  its  ad- 
ministration. Stimulating  and  nourishing  fluids 
must  he  Liberally  administered  at  regular  inter- 
\als.  and,  notwithstanding  the  difficulty  in  swal- 
lowing, the  nurse  should  insist  upon  its  being 
taken.  Many  a  fatal  ease  can  he  laid  to  the 
charge  of  carelessness  in  nursifig,  where  the 
wishes  of  the  patient  are  permitted  to  regulate 
ihe  nurse 'a  duties.  Beef  tea,  eggs,  milk,  cus- 
tards, egg-nog  and  similar  articles  of  concen- 
trated fluid  nourishment,  with  wine,  must  he 
frequently  poured  down  the  throat  of  the  un- 
willing   patient,    and,    if   the     mouth    cannot    he 


->'>-  TKKATMF.NT    01    TKTANIS. 

sufficiently  opened,  the  inhalation  of  chloroform, 
or  the  etdermic  nee  of  morphine  should  be  used 
to  effect  it.  I  have  Been  excellent  results  with 
either  of  these  relaxing  agents,  I  have  t '« •  1 1 1 1 « 1 
porter  an  cxcellcnl  tonic  in  such  cases,  as  it 
combines  both  sedative,  nourishing,  and  stimu- 
lating or  supporting  properties.  Dnder  the  fre- 
quent inhalation  of  chloroform,  the  spasms  can 
often    he   kept    under    control. 

By  pursuing  the  above  course  of  keeping  the 
patient  quiet,  using  sedatives  with  forced  nour- 
ishment, iii i <  1  relieving  the  Loaded  intestines  by 
crotou  oil.  I  have  had  the  good  fortune  of 
ing  three  tetanic  patients  out  of  six  cases  which 
have  coin. •  under  my  personal  observation.  As 
tin'  three  first  cases  which  I  treated  were  all 
restored  to  health,  although  they  were  very 
severe,  1  imagined  that  I  hail  found  a  success- 
ful mode  of  treating  tetanus,  and  published  the 
same  in  the  Charleston  Medical  Journal  for 
1857.  Since  that  time,  I  have  had  three  cases 
under  observation  and  lost  them  all.  notwith- 
standing the  same  course  was  pursued  as  in  the 

BUCCeSflful    cases. 

When  the  patient  is  able,  constant  smoking 
of  strong  scgars  may  he  useful  in  quieting  the 
excited  nervous  system.     The  impression  among 


W00RARA    AS    A    IIEMKDY    FOR    TETANUS.  269 

many  observing  surgeons  is.  thai  the  patient  is 
destroyed  by  exhaustion — called  by  some  starva- 
tion. It  is  known  that,  if  the  patient  can  be 
kept  alive  to  the  sixth  day  after  the  attack. 
there  is  a  likelihood  of  his  recovery,  and  that 
by  the  tenth  day  he  may  even  he  considered 
convalescent.  If  the  debilitating  effects  of  the 
disease  can  he  counteracted  by  the  free  admin- 
istration of  very  nutritions  food,  such  as  brandy 
and  eggs,  etc.,  many  surgeons  believe  that  the 
nervous  irritation  will  wear  itself  out.  It  is 
based  upon  this  belief,  and  the  known  failures 
of  the  spoliative  plan  of  treatment,  that  the 
ahove  plan  is  now  recommended. 

Wborara  poison  has  been  recommended  as  an 
antidote,  from  its  known  powerful  sedative  ner- 
vous action  and  its  marked  influence  in  counter- 
acting the  effects  of  strychnia.  When  poisonous 
doses  of  these  substances  are  given  conjointly, 
nn  poisonous  effects  are  observed.  The  strik- 
ing similarity  between  the  spasm-  produced  by 
strychnine  and  those  of  lockjaw,  suggested  the 
f  woorara  in  tlii>  latter  disease.  As  experi- 
ments proved  it  efficacious  in  the  tetanus  of 
animals,  its  field  of  usefulness  was  enlarged  to 
the  human  Bubject.  Several  cases  <•!'  it-  success- 
ful use  in  chronic  tetanus  are   reported.     Tli  sre 


L'7<>  EfSCTTC   n:vKR. 

is  much   difficulty   in    obtaining  g I   specimens 

of  ilii>  remedy.  A-  no  two  possess  similar 
properties,  each  musl  be  tested  by  experiment 
before  it  can  1»<'  tried  upon  the  human  subject. 
I  are   reported    where   its   use  hastened   the 

death  of  the  patient.  It  was  first  used  by  inoc- 
ulation, now  it  is  administered  in  the  form  of 
a  mixture:  ten  grains  of  the  wdbrara  to  a  six 
ounce  mixture — a  taBlespoonful  everj  half  hour 
until  perfect  relaxation  is  produced.  Should 
tnous  effects,  with  death-like  symptoms, 
show  themselves  from  an  over-dose,  artificial 
respiration  will  aupport  life  and  sustain  the  ac- 
tion of  the  heart  until  the  poison  js  eliminated 
from  the  circulation  by  the  kidneys.  The  ra- 
tionale of  the  remedy  is  to  keep  the  spasms 
from  killing  the  patient  by  their  violence,  until 
the  morbid  state  calling  them  into  play  has  ex- 
hausted  itself. 

Prom  the  known  influence  of  quinine  in  di- 
minishing the  pulse,  and  its  tendency  to  mitigate 
spasms,  many  consider  it  a  nse&l  drug  in  teta- 
ny .  and  Bpeak  of  it  as  a  remedy  well  worthy  of 
trial. 

Ebctio  Pbtbe. — The  not  a&frequent  sequela 
of  severe  gunshot  wounds  is  Long-continued  dis- 


EBECTio  fever.  271 

charge,  producing  emaciation  and  hectic,  with 
its  gradual  dissolution  of  body  and  soul.  It  is 
not  at  all  surprising  that  the  daily  discharge  of 
a  wound,  when  at  all  profuse,  should  cause  de- 
bility, as  we  have  already  characterized  pus  as 
the  nutritive1  essence  of  the  circulating  fluid.  If 
the  surgeon,  who  has  many  suppurating  wounds 
under  his  care,  overlooks  the  fact  that  lie  must 
make  allowance  for  this  drain  and  feed  the 
wound  as  well  as  the  patient,  the  wound  being 
more  imperious  in  its  demands  than  t]\e  econo- 
my, deprives  the  latter  of  its  due  supply  of 
nourishment,  and  progressive  starvation  must 
follow.  It  is  on  this  account  that  what  is 
called  the  antiphlogistic  treatment,  when  fully 
carried  out  in  the  treatment  of  suppurating 
wounds,  is  injurious,  and  that  the  supporting 
plan   is  required. 

With  diet,  we  have  a  powerful  weapon  for 
weal  or  woe  in  surgical  practice.  Soon  after 
injuries  have  been  received,  when  reaction  runs 
high,  by  abstemiousness  we  can  do  much  to 
quiel  excessive  irritability.  But  as  soon  as  this 
stage  has  passed,  and  suppuration  has  become 
established,  then  the  course  of  diet  should  be 
modified  :  now,  liberal  diet  is  necessary  to  pre- 
vent    the     febrile     coin]  .licat  ion,     which,     in     the 


272  in  <  tic  ikvi:k. 

early   stage   of  the    wound,    abstemiousness  con- 
trolled. 

The  use  of  an  abundance  of  strong,  nutritious 
food,  by  enriching  the  blood,  will  increase  the 
vital  properties  of  the  plasma,  improve  the  tone 
of  the  ti  op  tin-  excessive  demands  of  the 

irritated  wounded  parts,  and  diminish  the  drain. 
This  treatment,  with  Ifce  Libera]  use  of  the  astrin- 
gent tonics,  and  the  injectiou  of  stimulating 
astringents  into  the  wound  (as  nitrate  of  silver, 
tun  grains  to  one  ounce  of  water,  or  tincture  of 
iodine,  or  the  acid  tinetures  of  Iron  diluted,  one 
part  to  five  of  water),  will  gradually  diminish 
a  discharge,  which,  ander  less  supporting  treat- 
ment, would  continue  lor  a  much  Longer  period. 
The  economy  cannot  withstand  this  constant 
drain  :  it  becomes  irritable  in  its  weakness.  In 
its  efforts  t<>  throw  off  tie'  yoke,  it  still  further 
enfeebles  itself.  Daily  fevers,  with  their  profuse 
sweats,  reappear  with  fearful  regularity.  Finally, 
the   blood    heroines  so    poor,  that  it   deteriorates 

rapidly,  and  the  useless  material  which  is  ejected 
from  the  circulation,  irritating  the  organs  through 

which  it  passes,  causes  diarrhea,  and  also  copious 
deposits  in  the  urine.  The  quadruple  drain  from 
wound,    -kin.    bowels    and     kidneys,    cannot     long 

he  resisted.     Debility  gradually  increase.-,  the  pa- 


PERIODIC'    PAINS.  373 

tient  rapidly  wastes  to  a  living  skeleton,  having 

literally  melted  ;nvav.  and  at  last  dies  from  sheer 
exhaustion — the  conjoined  result  of  malnutrition 
and  wasting  discharges.     Such  is  hectic  fever. 

Periodic  Pains. — Another  sequela  ^i'  gunshot 
wounds  is  more  or  less  permanent  or  periodic  pom 

in  the  injured  limb,  connected  or  not  with  par- 
alysis of  certain  muscles  —  the  nervous  supply 
to  which  has  been  impaired  by  the  hall  in  its 
passage.  When  a  nerve  has  been  completely 
divided,  permanent  paralysis,  with  atrophy  of  the 
muscles,  ensues — the  limb  gradually  dwindling,  if 
the  muscles,  indirectly  destroyed,  be  important 
to  the  common  movements  of  the  extremity.  A 
bruising  of  the  nerves,  without  division,  is  also 
followed  by  a  paralysis  more  or  less  persistent, 
which  time,  however,  and  stimulating  embroca- 
tions will,  to  a  great  extent,  remedy. 

This  is  not  so  much  the  case  in  sabre  wounds. 
Where  a  nerve  is  divided  by  a  sharp,  cutting 
instrument,  when  the  tissues  are  not  displaced 
and  the  wound  heals  without  suppuration,  both 
experiments  upon  animals  and  experience  in  man 
show   that    a     reunion    of    the   ends   of    the    nerves 

is  effected,  and  nervous  action  restored  to  its 
former  integrity. 


L'7  I  raftlODIG    PAINS 

When  nerves  are  pricked,  or  in  any  other  way 
injured  withoul  eomplete  division,  very  Bevere 
neuralgic  pains,  with  spasmodic  action  of  the 
muscles  of  the  limb,  arc  occasioned.  These  pains 
extend  ap  and  down  the  injured  Limb,  and.  as 
in  oases  reported  by  Guthrie,  have,  with  irregu- 
lar intermissions,  annoyed  the  patient  for  years. 
In  one  case,  although  the  severity  o\'  the  symp- 
toms subsided  after  six  or  seven  years,  annoy- 
ance was,  at  times,  experienced  forty  years  after 
the  injury  had  been  received.  A  coldness  of 
the  parts  supplied  by  she  injured  nerve  is  not 
an  uncommon  effect,  and  is  more  or  Less  persist- 
ent. Sudden  changes  in  the  temperature,  cold 
weather,  or  mental  excitement,  are  among  the 
exciting  causes  of  such  attacks.  The  best  means 
of  mitigating  the  suffering,  independently  of  the 
application  of  warm  flannels,  is  the  free  use  of 
stimulating  narcotic  embrocations.  Any  combi- 
nation from  the  many  articles  of  the  materia 
medica,  of  stimulating  and  narcotic,  or  anesthetic 
ingredients,  would  fulfil  the  indications  of  treat- 
ment.  The  internal  use-  of  quinine,  aconite. 
hyoseyamus,  belladonna  or  opium,  will  blunt 
sensibility. 

The  endermic  use  of  morphine  in  one-fourth 
grain    doses,    or    aconitine,    one-sixteenth    of   a 


PERTOmr    PATNS.  275 

grain  dissolved  in  two  or  three  drops  of  water. 
will  give  immediate  relief — in  some  instances  a 
permanent  cure  lias  followed  the  firet  injection. 
Great  reliance  will  hereafter  be  placed  upon  this 
new  method  of  treatment.  A  Complete  division 
of  the  nerve  at  fault  has  been  recommended, 
and  practiced  with  some  good  results:  but  the 
divided  nerve  is  liable  to  become  diseased,  or  its 
cut  ends  swell  into  a  neuroma,  which,  incorpor- 
ating itself  with  the  cicatricial  tissue.  Would,  from 
the  amount  of  pressure  exercised  by  the  new 
formations,  allow  of  only  temporary  relief. 


I    MATT  K  R     VII. 

Treatment  of  wounds  of  th  different  parts  of  the  body, 
or  topical  surgery — Wounds  of  th  head — Concus- 
sion; Us  characters  and  treatment — Compression; 
Us  symptoms — Variety  of  wounds  of  the  head; 
their  prognostic  ruin, — Simple  wow/id  of  the  scalp ; 
treatment — Vracture  without  depression;  course  to 
be  pursued  when  mftammaium  of  the  brain  threat- 
ens—  Uracture,  with  depression,  to  be  treated  with- 
out an  operation — Trephining  very  rarely  called 
for — Compound  fracture,  with  depression  and 
pression  ;  trephining  even  here  of  doubtful  propriety 
—  Perforating  wounds  of  the  cranium  complicated 
with  foreign  bodu  s. 

Wounds  of  the  head,  when  received  in  battle, 
require  ;i  special  treatment,  which  cannol  be 
engrossed  in  the  routine'  practice  fdr  wounds. 
Owing  to  the  proximity  <>f  the  brain  and  mem* 
branes,  and  the  facility  with  which  Bhocks  or 
direcl  injury  can  be  transmitted  through  the  pro- 
tective envelopes,  injuries  of  the  head  possess  a 
peculiar  significance.      All  wounds  of  the   head 


CONCUSSION.  277 

are  more  or  loss  serious,  as  the  Burgeon  can  never 

know  in  advance  whether  the  brain  be  injured, 
and  what  amount  of  irritation  or  inflammation 
will  ensue  upon  such  an  occurrence.  Hence  the 
necessity  of  caution  in  prognosis  and  treatment, 
which  the  experienced  surgeon  will  always  ex- 
hibit,  however  trivial   the  wonnd  may  appear. 

Injuries  of  the  head  wonld  divide  themselves 
into  those  produced  from  shot,  those  from  the 
bayonet  or  clubbed  musket,  and  those  caused  by 
the  blow  of  a  sabre.  Wounds  are  found  of  every 
grade  of  intensity,  from  a  simple  scratch  to  ex- 
tensive destruction  of  the  soft  and  hard  parts, 
with  or  without  those  phenomena  recognised  as 
concussion  and  compression.  As  these  terms 
will  be  continually  referred  to  in  speaking  of 
the  treatment  of  head  injuries,  we  will,  in  brief, 
define  the  meaning  which  the  surgeon  attaches 
to  them. 

( 'minis*;, ,n.  or  stunning,  appears  to  be  a  shock 
to  the  brain,  by  which  its  substance  is  more  or 
leai  shaken,  with  interference  of  its  circulation, 
and  often  injury  to  its  structure  —  its  functions 
bring  suspended  for  a  certain   period. 

Immediately  as  an  injury  upon  the  head  has 
been     received,    if    at     all     severe,     the     patient     is 

knocked  senseless       He  lie-  perfectly  insensible 


•J7^  SYMPTOJM    "I     OOMC1  B8ION. 

motionless,  ami  all  but  pulseless.  Hi-  face  ami 
surface  becomes  pale  ami  cool;  tin-  breathiug, 
althougb  feeble,  i>  regular  ami  easily  peroi 
the  pupils  Irregularly  contracted  or  dilated*; 
sphincters  arc  relaxed,  in  common  with  tin-  en- 
tire voluntary  muscular  Bystem,  so  iliat  the  con- 
teuta  "I'  the  bladder  and  bowels  often  escape 
involuntarily.  After  continuing  in  this  condition 
for  a  few  minutes,  hours  or  days,  he  gradually 
recover-  consciousness.  The  heart  first  regains 
it-  accustomed  action,  tin'  pulse  gradually  under* 
goei  development,  and  the  skin  becomes  wanner. 
At  this  period  vomiting  usually  comes  on,  which 
arouses  the  action  of  the  heart.  This  organ  un- 
der the  excitemenl  of  emesis,  drives  blood  i<>  the 
brain,  ami  with  this  free  supply  <•!'  stimulus  to 
the  general  controlling  organ,  the  patient  rapidly 
rallies. 

This  is  the  common  picture  of  concussion  as 
.-ecu  in  surgical  practice,  and  the  combination  of 
its  symptoms  will  he  more  familiarly  recognized 
as  those   ft'  ordinary  fainting   or  Byncope.     The 

extremes  would  he  those  Cases  in  which  the  pa- 
tient staggers,  hut.  after  supporting  himself  for 
an  instanl  against  some  house,  fence  or  tree, 
recovers  himself,  and  without  further  annoyance 
continues  bis  employment;  or  those  in  which  tin- 


TATnOLOGY    OF    CONCUSSION.  279 

patient  is  picked  u]>  apparently  (load,  with  re- 
laxed muscles,  pale  surface,  glassy  eve,  scarcely 
perceptible  pulse,  and  very  feeble  and  irregular 
respiration.  The  death-like  appearance  becomes 
more  and  more  continued,  the  breathing  gradu- 
ally ceases,  and  the  pulse  imperceptibly  tlitters 
away,  without  any  sign  of  consciousness  from  the 
moment  of  injury. 

In  fatal  cases,  where  concussion  bad  been 
present,  the  brain  has  been  found  more  or  less 
injured,  and  so  highly  congested  as  to  exhibit  a 
dusky  hue.  Fissures  have  been  found  in  its  sub- 
stance, or  extravasations  of  blood  in  numerous 
or  concentrated  spots.  Tn  certain  instances,  the 
brain  has  apparently  shrunk  from  the  excessive 
skaking  or  vibrations  to  which  it  has  been  sub- 
jected, so  that  it  no  longer  tills  the  cavity  of  the 
skull.  In  some  fatal  eases,  where  the  brain  bad 
been  fissured,  the  commotion  among  its  particles 
had  at  once  annihilated  its  functions,  so  that  the 
heart's  action  had  instantly  ceased,  and  no  blood 
had  been  driven  to  the  mangled  brain  to  be  ex- 
taavasated  into  it-  substance.  In  cases  oi  nearly 
instantaneous  death  from  concussion  or  stunning, 
the  brain,  on  examination,  appeared  in  every 
respeel   bealthy.     <>n  the  other  hand,  in  eases  of 

perfed    recovery   after    concussion,   where    llie   pa- 


PATHOLOGY    "T    CO  NCI   SSION 

liciit  had  lived  some  time  (weeks  or  month 
the  lull  enjoyment  of  all  his  faculties,  and  had 
died  from  some  disease  totally  foreign  t<>  the 
former  head  injury,  extensive  lesions  have  l>*«n 
fonnd  in  tli<-  brain,  and  traces  of  large  and  ex- 
tended extravasations  of  blood  covering  the  hem- 
ispheres as  well  as  in  the  cerebral  substance. 
The  irritable  condition  <>f  the  brain  in  which  the 
patient  is  often  left,  after  concussion  of  limited 
duration,   with   the   impairment   <>!'  memory,  Of  ©f 

boh ue  of  the  special   senses,  or  even    partial 

paralysis,  would  be  physiological  proof  of  cere- 
bral injury.  Although  its  symptoms  are  usually 
transient,  we  may.  doubtless,  consider  it  a  con- 
tusion or  interstitial  laceratiou  of  brain  >ul>- 
stance. 

As  this  is  an  alarming  condition,  t>>  those  not 
lamiliar  with  the  march  of  Buch  lesions,  those 
interested  in  the  injured  man  art-  always  clamor- 
ous  for  active  interference,  and  it  is  with  diffi- 
culty that  th<'  Burgeon  can  free  himself  from  the 
argent  solicitations  of  friends  who  believe  that, 
unless  prompt  means  arc  used,  the  accident  must 
terminate  fatally.  The  surgeon,  under  such  cir- 
cumstances, requires  all  of  his  p  of  mind, 
and  with  firmness  should  strictly  pursue  the  non- 
interference plan  of  treatment 


TKKATMi'.vr   of   CONCUSSION.  281 

The  course  which  rational  surgery  now  recom* 
mends  is  to  lay  tin1  patient  horizontally,  with 
hie  head,  perhaps,  a  little  lower  than  his  body, 
so  that  the  brain  may  have  the  benefit  of  gravi- 
tation  to  assist  in  its  supply  of  blood.  lie  is 
wrapped  in  warm  blankets,  hot  bottles  are  placed 
around  his  body,  and  dry  frictions  may  be  used 
to  excite  the  re-establishment  of  the  circulation 
in  the  extremities;  hut  beyond  this  the  surgeon 
should  not  interfere.  The  safest  practice  consists 
in  doing  as  I<'f/ft  as  possible.  The  use  of  stimuli  on 
//!(  om  hand  <</•  bleeding  <>i<  lh<'  other,  are  to  be  espe- 
cially "in/  studiously  avoided. 

Only  a  few  years  since  bleeding  was  the  prac- 
tice in  stunning,  and  the  amount  of  mischief  done 
by  this  universal  mania  for  bloodletting  was  often 
irreparable.  We  might  as  well  bleed  in  a  faint- 
ing tit  and  expect  good  results.  We  find,  as  in 
syncope,  that  the  heart  scarcely  pulsates;  SO  little 
blood  is  driven  to  the  surface  1 1 1 ;i t  it  is  pale  and 
cold.  The  same  for  the  brain,  where  so  little 
flood  circulates  that,  from  want  <>f  its  proper 
stimulus,  its  functions  are  temporarily  suspended. 
Were  it  ] . < » r- - j  1  •  I < ■  t,»  draw  away  much  flood,  the 
tion  of  the  nervous  functions  would  become 
permanent. 

Modern  Burgcry,  in  studying  the  natural  history 

L'l 


282  TUK ATM1N  I     01    0ON<   I   38T0N. 

of  <  1  i s < ■ : i - « ■  s  mid  Injuries,  perceives  now.  what  it 
should  long  Binoe  have  recoguized,  thai  nature, 
in  her  desire  to  harbor  the  circulating  fluid,  tries 
to  pin  ;i  safeguard  agaiust  the  rashness  of  Bur- 
geons, 1'v  shutting  up  the  bulls  of  this  living 
fluid  in  the  inner  red  ee  of  the  body,  when  it 
cannot  be  easily  despoiled.  On  accounl  of  this 
change  in  practice,  we  now  seldom  hear  of  deaths 
from  concussion,  which  was  comparatively  of  com- 
mon occurrence  a  few  years  hack. 

As  regards  stimulation,  we  must  also  desisl  as 
long  as  it  is  possible,  and,  when  its  administra- 
tion is  compulsory,  give  it  with  a  most  cautious. 
Bparing  hand.  Remember  that  the  degree  ami 
duration  of  shock  depends  upon  the  extent  of 
injury  which  the  brain  lias  received,  ami  that 
nature  always  the  most  skilful  physician,  adopts 
this  concussion  as  a  safeguard  to  prevent  further 
mischief.  I  low  are  we  to  know  that  the  brain 
has  not  sustained  severe  injury,  extensive  bruising 
or  laceration,  and  that  this  extreme  depression  of 

the  system,  with  consecutive  control  of  the  heart's 

action,  is  not  especially  indicated  to  prevent  hem- 
orrhage within  the  brain  substance,  and  rapid 
death  from  compression  by  extravasated  blood? 
We  know  this,  that  after  severe  injury  to  the 
brain,  when,  through  officious  meddling  and  the 


TREATMENT    OF    CONCUSSION.  283 

five  use  of  brandy,  the  symptoms  of  concussion 
early  disappear,  violent  reaction  is  induced,  and 
internal  hemorrhage  or  violent  inflammation  soon 
shows  itself;  and  that,  for  the  doubtful  gratifica- 
tion of  seeing  the  patient  rapidly  revive,  we  have 
the  mortification  of  seeing  him  as  rapidly  de- 
stroyed. 

Oases  of  concussion,  absolutely  requiring  stimulants, 
are*  but  very,  very  seldom  met  with  in  practice.  Even 
when  of  a  very  severe  form,  all  that  is  necessary, 
in  the  vast  majority  of  cases,  is  to  apply  warmth 
to  the  surface,  and    carefully  to  watch    the   case. 

Should  it  so  happen — hut  this  occurs  very  rare- 
ly— that  the  patient  is  manifestly  in  danger  of 
sinking  from  depression  of  the  circulation,  then 
stimulants  must  he  resorted  to.  As  long  as  the 
pulse  does  not  lose  its  strength  under  concussion 
of  the  brain,  desist  from  active  interference,  al- 
though the  insensibility  last  for  hours  or  even 
days.  After-trouble  will  he  avoided  by  allowing 
nature  to  take  its  own  course  unmolested.  When 
from  the  great  and  long-continued  depression 
stimuli  are  called  for  to  prevent  threatening  dis- 
solution, their  effects  should  he  carefully  watched, 
ami.  as  Boon  as  reaction  is  apparent,  with  an  im- 
proving pulee,  :it  once  desist  from  rurthei  inter- 
ference.     As  is  the  state  of   depression,   so  will 


284  OOHPRSSSION. 

be  the  state  of  reaction.     WheD  the  depreeeioa 
is  extreme,  1 1 1 « •  reaction  will  be  correspondingly 
re,  and  especially  bo,  if  stimuli  have  been 
freely  administered. 

When  the  patient  has  recovered  from  the  state 
of  insensibility,  be  Bhoald  be  kept  perfectly  quiet; 
excitement  of  every  kind  should  be  carefully 
avoided,  the  diet  Bhould  be  abstemious,  Ehe  head 
kept  cool,  and  tendency  to  constipation  cor- 
rected. Beyond  thia  no  treatment  is  required 
until  expressly  called  for  by  excessive  reaction, 
with  Bymptoms  of  congestion  or  inflammation  ef 
the  brain.  The  precautionary  bleeding,  with  re- 
peated <l<>scs  of  calomel,  to  keep  off  Bymptoms 

which,    in    the   majority   of  Oases,    would    not    have 

occurred,    was    the    routine   practice    of  the   <>ld 

school,     and     cannot     be     too     severely     criticised. 

The  complications  which  might   arise  in  injuries 

of   the   head,    after    more    or    less    serious    concus- 
sion, will  be  hereafter  considered. 

Compression.  —  Concussion  is  always  simulta- 
neous with  the  blow,  and  gradually  decreases,  it' 
death  does  not  carry  oil' the  patient  at  an  early 
period.  Compression,  the  condition  with  which 
it  is  often  allied,  usually  comes  on  some  little 
time   after  the    reception    of  injury,   although   it 


SYMPTOMS    OF    COMPRESSION.  285 

may  appear  either  at  the  moment,  or  may  not 
show  itself  for  days,  or  even  weeks,  after  the  in- 
jury. The  name  explains  the  lesion.  Compres- 
sion is  pressure  made  upon  the  brain,  either  by 
a  portion  of  the  skull  or  some  foreign  body  driven 
into  or  upon  the  cerebral  mass;  or  by  an  escape 
of  blood  from  some  torn  vessel,  which,  by  forc- 
ing itself  into  the  unyielding  skull,  compresses 
its  contents,  or  by  an  effusion  of  lymph  or  pus, 
which  inflammation  causes  to  be  deposited  within 
the  cavity  of  the  skull. 

The  symptoms  by  which  this  condition  would 
be  recognized,  are  as  follows:  The  patient  lies 
in  a  state  of  coma,  stupor,  or  lethargy — being 
paralyzed  more  or  less  completely,  both  as  re- 
gards motion  and  sensation,  lie  is  heavy,  insen- 
sible, and  drowsy;  at  times  answers  mutteringly 
when  rudely  shaken  or  loudly  spoken  to,  but 
immediately  afterward  is  again  breathing  slowly, 
heavily  and  laboriously,  as  if  in  deep  Bleep. 
Should  his  t'aee  be  examined,  the  lips  and  cheek 
on  one  side  will  be  found  to  flap  during  expi- 
ration, with  a  blowing  sound,  as  if  smoke  was 
being  blown  from  the  mouth  as  in  smoking. 
There  is  paralysis  of  that  side  of  the  body  op- 
posite  to  the  seal    of  injury,   and.   as   a    necessary 


B86  SYMPTOMS    Off   OOMffKBSSION 

consequence,  both  in  expiration  or  in  attempts 
:ii  speaking,  the  corner  of  tin-  month  is  drawn 
over  t"  the  sound  side.  The  counteuan< 
usually  pale,  cold,  ;ui<1  ghastly,  although  it  may 
be  flushed,  with  a  1  * « » t  and  perspiring  skin:  the 
eyelids  ;uv  partly  or  completely  opened,  with  the 
pupils  dilated  and  insensible  t<>  light;  the  pulse 
is  slow,  the  heart  acting  under  greal  oppression  ; 
there  is  constipation  from  torpidity  of  the  bowels, 
with  involuntary  discharge  of  the  faeces.  From 
want  of  action  in  the  bladder  the  urine  is  re- 
tained, and,  unless  drawn  oil*,  will  decompose 
within  the  organ,  when,  from  accumulation,  either 
the  bladder  will  rupture  with  poisonous  infiltra- 
tion, or  the  blood  becomes  poisoned  from  absorp- 
tion. These  symptoms  are  not  always  equally 
marked — the  degree  depending  upon  the  cause. 
Unless  the  causes  of  compression  be  removed, 
the  ease  usually  terminates  fatally,  although  ease- 
are  not  rare  in  which,  after  weeks  of  uncon- 
sciousness, reason  has  gradually  been  restored — 
the  accompanying  paralysis  slowly  disappearing. 
Having  now  explained  the  two  conditions  of 
concussion  ami  compression,  which  so  commonly 

accompany  Bevere  wounds  of  the  head,  we  are 
heiier  prepared  to  study  this  special  class  iA'  in- 
juries. 


DISEASES    OF    HEAD    INJURIES.  287 

The  divisions  which  experience  lias  proved  of 
practical  utility,  are  : 

1.  Injury  to  the  soft  parts  alone,  uncompli- 
cated  "WITH    INJURY    TO    SKILL   OB    BRAIN. 

-.  Wound  op  soft  parts,  with  simple  frac- 
ture  OF   THE    SKULL. 

3.  Wound   with   depressed   fracture   of   the 

SKULL,    RUT    WITHOUT    SYMPTOMS    OF    COMPRESSION. 

4.  Compound  depressed  fracture  of  the  skirl. 

WITH    SYMPTOMS    OF    COMPRESSION    OF    Till;    RRAIX. 

5.  Perforating  woi  ni>s  of  the  skull,  compli- 
cated  WITH   FOREIGN   BODIES. 

From  the  peculiar  formation  of  the  skull,  and 
the  resistance  which  it  offers  to  Mows,  unless  a 
shot  strikes  it  fairly  at  right  angles,  it  does  not 
perforate;  but  whether  it  be  a  grape,  musket,  or 
pistol  ball,  it  Hies  off  at  a  tangent,  and  running 
beneath  the  skin  upward,  downward,  or  laterally, 
escapea  The  head  may  even  be  struck  with  a 
round   shot   without  serious   injury. 

The    patient    may,   or    may    not    be    knocked 

down    by   the    blow;    severe    pain     is    felt,   and     a 

puffing  up  of  the  part  instantly  follows.     When 

the  hair  is  remove],  although  there  may  be  uo 
discoloration  of  the  skin,  there  is  abundant  evi- 
dence of  subcutaneous  Lesion,  which,  unless  ooun- 


288  TRKATMKNT    Off    SIMIM,K    IH'.Ah    I  VI I  RIBS. 

tcracted,  will  soon  develop  inflammation  and 
extensive  suppuration.     The  severity  of  the  blow 

upon    the    head    may   have     knocked    the     patient 

senseless;  ami  in  this  condition,  he  La  found  hy 
the   litter  earners. 

The  transportation  of  head  injuries  requires 
great  care,  and  the  best  transports  should  be 
devoted  to  this  service.  When  the  patient  ar- 
rives at  the  Held  infirmary,  be  is  laid  down,  with 
the  head  low,  until  lie  recovers  himself.  The 
nation  is  left  to  nature:  cold  water  may  he 
dashed    into   the    face,    hut    all    stimulation    should 

be  avoided  unless  the  pulse  is  found  to  flag, 
when  a  little  brandy  may  he  cautiously  given. 
The  surgeon  takes  advantage  ^\  the  insensibility 

of  the  patient,  shaves  the  head  at  the  point  of 
injury,  and  gives  the  wound  a  thorough  exam- 
ination.      When     reaction    has    taken     place,    and 

the  patient  is  restored  to  consciousness,  should 
the  wound   have  been    a  simple  one  of  the  sofH 

parts,    the    cold    water    dressings    is    all     that    will 

he  required,  and  should  he  applied  according  to 
general  principles.  The  thin,  wet  compress,  with 
oiled   or   waxed    cloth,  should    cover  the   wound 

and    head    \'<>v    some    distance   around    the   injury; 

and  instead  of  tying  these  in  place  by  the  roll 
yi\'  bandage,  the  better  plan  i.>  to  adopt  the  bead 


TREATMENT    OP    SIMPLE    HEAD    IN.MH1ES.  281* 

net  of  the  Prussian  medical  service.  It  is  a 
round  piece  of  coarse  netting,  made  of  cotton 
yarn:  a  string  tics  under  the  chin  to  keep  the 
dressing  on,  and  a  drawing-string  running  around 
the  net,  Like  a  purse  string,  attaches  it  securely 
to  the  head  around  the  temples.  This  is  an 
admiral )le  dressing  for  all  head  injuries,  Which 
require  light,  cool,  and  efficient  applications. 

Should  the  soft  parte  have  been  much  bruised, 
the  ice  bladder  will  he  required  to  keep  down 
excessive  suppuration.  To  prevent  mischief,  all 
injuries  of  the  head  demand  rest  and  quiet, 
avoidance  of  stimulants,  and  abstemious  diet. 
By  adopting  this  course  in  uncomplicated  wounds, 
whether  gunshot  or  sahre,  a  speedy  cure  is  usu- 
ally obtained. 

Effusions  of  blood  under  the  skin  should  not 
he  interfered  with;  incisions  are  -not  required. 
If  the  effusions  are  allowed  to  remain  excluded 
from  air.  tlic  cold  water  dressings,  with  arnica, 
will  cause  their  rapid  absorption;  if  the  skin  is 
punctured  and  air  admitted,  suppuration  will 
surely  ensue.  Should  suppuration  occur,  as  soon 
as    pUS    can    he   clearly    detected,    let   it   out    by   a 

small  incision.    If  this  operation  he  not  attended 

to   at    the   pp. .per   time,  the    pent-up   pus  will   sepa- 
rate the  periosteum   from    the   skull,  and  cause, 


29U  TRKATMKNT    ><V    PRACTtTRI    OW    SKI   II 

perhaps,  a  necrosis  of  the  bones.  When  Buppn- 
ration  lias  been  well  established,  an  oiled  cloth 
i-  substituted  for  water  dressings,  by  many  sur- 
geons, although  the  growing  disposition  is  to 
continue  the  water  dressings  until  cicatrization 
is   completed. 

When  tin'  ihM  had  been  fractured  by  a  ball, 
sabre  blow,  ot  fragment  of  shell,  the  treatment 
should  in  no  material  respect  drffer  from  tin' 
course  pursued  in  simple  scalp  wound.  A  sim- 
ple or  compound  fracture  of  tin'  skull,  nncompli- 
cated  with  injury  t<>  the  brain  or  its  meninges, 
should  be  managed  according  to  the  ordinary 
principles  of  surgery^  remembering  always,  how- 
ever, that  the  braitt  is  in  rtear  proximity,  and 
may  have  hern  injured,  although  no  symptoms 
arc  present  for  detecting  such  a  lesion.  If  the 
patient  is  iinVnsihle,  Ave  adopt  the  means  already 
recommended  for  removing  shock,  viz:  place  the 
btidy  in  a  horizontal  posture,  and  leave  the  ease 
pretty  much'  to  nature — avoiding  everything  tend- 
ing to  internal  stimulation.  Whilst  Insensible, 
we  examine  the  wound  thoroughly,  usin£  the 
finger  as  a  probe;  and  if  any  loose  Spiculte  Of 
bone  be  felt  (pule  five  in  the  wound  and  uncon- 
nected   with    the    soft    parts,    they    should    he    re- 


TRKATMKNT    OF    FRACTUUK    OF    SKULL.  291 

moved.  If  attacked,  they  must  be  left  to  escape 
spontaneously  after  Suppuration   is  established. 

Gunshot  fractures  are  usually  distinctly  limit- 
ed to  the  portion  struck,  and  seldom  ramify  as 
do  fractures  from  diffused  blows.  It  is  this  con- 
centration of  the  force  within  a  small  compass, 
and  the  extended  injury  to  the  inner  tablet  of 
the  skull,  which  render  irunshot  injuries  of  the 
head   so  serious. 

When  we  are  satisfied,  from  a  careful  exami- 
nation of  the  condition  of  the  bones,  that  they 
remain  in  their  normal  position  without  depres- 
sion, the  head  is  shaved,  and  the  wound  care- 
fully closed  with  a  strip  of  adhesive  plaster  so 
as  to  exclude  air.  As  soon  as  the  patient  has 
revived,  the  cold  water  or  ice  treatment  is  at 
once  instituted.  Should  there  have  been  but 
little  shock  from  the  injury,  these  wet  applica- 
tions should  be  commenced  with  on  the  battle 
field. 

When  the  patient  is  put  to  bed  (which  should 
be  as  soon  as  possible,  for  early  treatment  is 
all-imp<>rtant),  his  head  and  shoulders  should 
be  elevated  :  quiet  and  absolute  rest  should  be 
strictly  enjoined  :  the  room  should  be  darkened  ; 
all  .-tiniuli,  including  light  and  noise,  should  be 
avoided  :   the   bowels  should   he   freely   opened    by 


292  TRKATMKM     OK    FRACTIRK    Of    BK1   II. 

a  saline,  mercurial,  or  Bloetic  cathartic;  ami  l'<>r 
a  few  days.  abstemious  diet  prescribed.  These 
precautions  are  necessary  t<>  prevent  irritation  of 

tli.'  brain,  willi  subsequent  < - « n i ir » ■  ^- 1 i « » 1 1 ,  intlamma- 
tion  and  effusion.  It*  the  patient  appears  irrita- 
ble and  peevish,  without  heat  of  head  or  fulness 
of  pulse,  give  <>]»iuni  to  quiet  him. 

Tin-  rase  should  be  watched  with  care,  and  if 
symptoms  of  congestion  of  the  brain  threaten, 
with  injection  of  the  face,  red  eves,  hot  skin, 
forcible  throbbing  of  the  carotids,  increasing 
headache,  with  an  early  tendency  to  delirium, 
the  patient  should  be  at  once  bled,  the  head 
should  be  shaved,  and  an  ire  bladder  be  assidu- 
ously applied  over  the  entire  scalp;  the  intes- 
tines should  be  freely  acted  upon  for  the  revul- 
sive effect  upon  the  brain,  and.  for  a  similar 
reason,  sinapisms  should  be  applied  to  the  legs 
and  thighs.  Should  relief  not  be  promptly  ob- 
tained, leeches  or  cups  might  be  applied  to  the 
mastoid  processes.  Calomel  was  formerly  the 
universal  prescription  for  threatening  cerebral  in- 
flammation.     Salivation  was  induced  as  early  as 

possible,  and  when   the  system  was  brought  under 

its  influence,  the  patient  was  considered  compar- 
atively sate  In  modern  BUrgery,  calomel  has 
lost  its  hi^h  position,  and   the,  dependence   upon 


TREATMENT  OF  FRACTURE  OF  SKULL.     293 

its    salivating    powers    is    annually   diminishing. 

Many   still   administer   it,   but  not  with    the    con- 
fidence of  former  times. 

Should  this  threatened  inflammation  not  sub- 
side under  this  course  of  treatment,  but,  after  a 
period  of  high  febrile  excitement,  the  delirium 
becomes  merged  into  stupor,  with  noisy  breath- 
ing, dilated  pupils,  slow,  labored  pulse,  relaxed 
Sphincters  and  paralysis,  the  case  indicates  com- 
pression from  effusion,  within  or  upon  the  brain, 
and  chances  tor  life  become  very  doubtful.  Per- 
haps a  thick  layer  of  lymph  may  have  formed 
upon  the  cerebral  surface,  or  a  quantity  of  serous 
fluid  collected  in  the  ventricles,  or  a  circum- 
scribed or  diffused  abscess  in  or  upon  the  brain. 
This  lymphy  effusion  sometimes  covers  the  entire 
surface  of  one  or  both  hemispheres.  The  arach- 
noidal membrane  appears  to  be  the  one  chiefly 
inflamed.  It  is  thickened,  semi  opaque,  adherent 
t<>  the  brain  surface,  and  reddened  in  patches. 
The     pit    mater    and    brain    substance    is   highly 

injected. 

It',  with  the  occurrence  of  these  symptoms,  the 
patient  lie  seized  with  chills,  the  scalp  wound 
becoming  dry.  and  the  tissues  puffy,  or  a  col- 
lection forms  under  the  periosteum,  lifting  this 
membrane  from  the  bones  which  appear  dry  and 


294  TREATMENT    OS    9BAC1VB1    Of    I R 1   I  I 

yellow,  it  would  indicate,  in  many  instances,  a 
circumscribed  collection  <>i'  pus  within  1 1 1  *  -  skull. 
These  symptoms  might  be>  bnl  very  rarely  arc 
relieved  by  the  nae  uf  the  trephine.  As  a  gen- 
eral rule,  tlif  operation  hastens  the  fatal  catas- 
trophy.  Unless  an  external  Sbscead,  with  the 
characteristic  puffy  scalp,  defines  the  collection 
of  effusions'  within,  the  trephine  should  not  be 
used.  It  often  happens,  after  trephining,  that 
these  supposed  collections  have  not  been  found, 
and  it  is  only  alter  tin-  operation  that  tin-  seem* 
tion  of  pos  has  been  established.     When  air  is 

admitted,   suppuration    is   certain  ;     whilst    without 

the  operation  the  effusions  are  known,  in  many 
instances,  to  have  been  absorbed — the  patient  re- 
covering alter  remaining  insensible,  in  one 

as   loug  as   twenty-one   days. 

Cole,  in   his   Military   Surgery,  mentions  eases 

of    fracture    of    the    skull     from    hall,    without     the 

skin  being  torn.  Unless  the  hones  arc  much 
detached,  as  they  were  in  one  of  his  cases,  the 

condition    can    only    he    BUSpected.       Such    injuries 

must  he  treated  under  the  antiphlogistic  expect- 
ant plan.  An  nil  symptoms  before  <ti-tic<  surgical  >n- 
tbrferenci   is  instituted,  <tn<l  we  Will  never  r<</rt/  it. 

There    are    a    series    of    cases;    in    which     injury 
to    the    skull    is   complicated    with    internal    hleed- 


TREATMENT    OF    FRACTURF.    OF    SKULL.  295 

ing.  The  insensibility  which  seized  the  patient 
at  the  moment  of  injury  will  pass  off,  and  the 
consciousness  will  be  regained,  but  only  for  a 
time.  The  patient,  after  a  longer  or  shorter  in- 
terval, feels  heavy  and  dull,  and  indisposed  to 
exertion;  finally,  a  strong  disposition  to  sleep 
domes  over  him,  which,  deepening  into  coma, 
ends  in  all  the  symptoms  of  well  marked  C( im- 
pression. This  is  an  instance  in  which  the  sur- 
geons, of  twenty  years'  since,  would  have  tre- 
phined, as  the  only  chance  of  saving  the  patient. 
Now  we  would  lay  down  an  equally  broad  rule, 
that  his  only  hope  of  recovery  is  in  avoiding 
the  trephine.  Pursue  a  rigidly  antiphlogistic 
course.  Free  venesection,  when  assisted  by  iee 
Madders  to  the  entire  scalp,  will  stop  further 
loss  of  blood,  reduce  the  action  of  the  heart, 
and  permit  the  effused  blood  to  clot,  so  as  to 
•  •lose  the  openings  in  the  torn  blood-vessels; 
then,  by  free  purgation,  act  upon  the  bowels, 
both  tor  a  derivative  effect,  and  to  promote  the 
absorption  of  the  effusion.  If  yon  can  stop  the 
farther  escape  of  blood,  that  which  has  been 
ell'used  will  gradually  be  removed,  and  the  symp- 
toms of  compression  will  as  gradually  pass  off, 
after  having  continued  for  days,  or  even  weeks. 
Trephine  such  a  patient,  and  what  certainty  have 


_'!••',  TREATMENT    "i     FRACTURE    01    >M  u 

vv€  thai  we  will  ftnd  the  point  where  hemorrhage 
bee  taken  place,  of  thai  the  Mood  i-  still  fluid 
ami  cau  be  nsmoved — both  very  improbable  re- 
sults. Blood-vessels  may  bave  given  way  ai  any 
other  portion  of  the  brain  than  at  the  portion 
corresponding  to  the  point  where  the  skull  is 
injured.  The.  recoil  of  the  contents  <>f  the  skull 
may  have  raptured  vessels  diametrically  opposite 
to  the  injured  point.  Autopsies  not  unusually 
reveal  such  conditions. 

The  operation  "t*  trephining  is  always  very 
Berious  /"/•  at,  and  is  sufficient  of  i t >•*■  1 1"  to  cause 
cerebral  or  meningeal  inflammation,  which  will 
nearly  always  terminate  fatally.  The  operation 
is  often  more  serious  thai  the  condition  for 
which  it  is  used,  and,  although  the  patient 
might  recover  from  cither,  he  succumbs  under 
the  combination.  Experience  and  autopsies  have 
shown  us  many  oases  of  extensive  intra-craniaJ 
hemorrhage,  which  have  been  unaccompanied  by 
symptoms  denoting  such  an  accident  ;  and  the 
traces  of  such  have  been  found  when  the  pa- 
tient,   recovering    from    his    head    injury,    had,    at 

some  subsequent  period,  fallen  a  victim  to  a 
totally  foreign  disease.  Had  such  a  condition 
been  inspected,  and  the  surgeon  used  his  instru* 
ments,  an   autopsy  at   a  much  earlier  day  would 

have   revealed   the  condition. 


TKKATMKNT    00    FRACTURE    OF    SKCT.l,.  L".l7 

7  he  third  variety  <>/  mjvry  oj  the  head,  with  de~ 
prossion  of  the  skull,  belongs  to  a  more  serious 
<-l:iss  of  woui^ls.  The  complication  is  detected 
at  once  by  examining  the  wound  with  the  tin- 
ker, when  the  sinking  of  the  boties  is  felt,  tlic 
extent  of  injury  is  detected,  and  the  condition  of 
the  depressed  portion,  whether  en  masse  or  spicu- 
lated,  determined.  The  broken  fragments,  if  quite 
loose,  should  be  removed  within  the  first  twenty- 
four  hours  after  the  injury  and  before  reaction 
,sets  in.  When  concussion  lias  passed  off,  and  no 
symptoms  exist  indicating  injurious  pressure  upon 
the  brain,  the  case  should  be  treated  in  even- 
respect  as  if  no  depressed  fragments  existed.  Un- 
less we  see  clearly  that  the  bone  is  very  much 
-piculated,  and  that  sharp  fragments  are  pierc- 
ing the  meninges,  avoid  all  instrumental  interfer- 
ence, even  to  dilating  the  wound,  for  the  pur- 
pose <>f  facilitating  a   more  accurate  diagnosis. 

We  should  never  be  anxious  to  set'  the  symp- 
toms of  concussion  rapidly  disappear:  let  nature 
abide  her  time:  watch  the  case,  and  ^<'<.  that  the 
patient  sutlers  no  detriment.  Examim  frequently 
t/u  pulse,  but  i")i  flu  head,  and  as  long  as  it  sustains 
its,  if.  everything  is  working  to  tin  <t</f<ri,ti'</<  of  the 
wounded.  With  a  rapid  reaction,  torn  blood-ves* 
sals  may  not  have  had    time  to  become  plugged 


TRKAT\U  \T    Of    KKA<'IIKK    00    -Kl   1.1 

up,  ;ui<l  internal  hemorrhage,  which  is  always 
serious,  mighl  BBSlMh  A-  Soon  ;i-  the  pulse 
commences  to  improve,  then  we  qpmmence  cold 
applications,  which,  if  assiduously  applied,  may 
prevent  the  after-venesection*  When  bloodied 
ting  is  required,  it  is  preferable  to  bleed  moder- 
ately from  •  large  opening',  to  be  repeated,  it' 
necessary,  than  to  draw  away  a  large  quantity  of 
blood.  Tin-  object  is  to  obtain  a  sedative  and 
revulsive  effect,  and  to  despoil  to  as  limited  an 
extent  as  possible,  [f  from  six  to  tei  ouneeeve 
from  a  Large  opening  in  the  vein,  will  produce  a 
sensible  feeling  of  faintness,  do  not  draw  from 
sixteen  to  twenty.  ODhis  Bedative  effect  might  be 
sustained  by  leeches  or  cape  to  the  ne.-k.  and 
by  small  doses  of  tart,  emetic,  verati'um  viride, 
or  digitalis — never,  however,  pushing  these  reus* 
dies  to  vomiting,  which,  by  tending  to  congestion 
of  the  head,  would  art  injuriously.  Uevulsives 
to  the  intestines*  as  recommended  in  the  treat- 
ment of  simple  fraetures,  with  IOS  to  the  head, 
are  the  remedies  upon  which  most  reliance  il  to 
be  placed.  Free  purgation  is  uo1  desirable,  as  the 
frequent  change  of  position  would  be  injurious 
i,,  the  patient,  should  the  integuments  and 
pericranium    inflame,  with    much    swelling,  pain, 

tension,    and    with    febrile    reaction,    incisions,    or 


TREATMENT    OF    FRACTURE    OP    SKULL.  '-90 

rather  scarifications,  may  be  made  to  release  the 
pent-up  fluids.  These,  if  possible,  should  he 
node  at  a  distance  from  the  seat  of  fracture — 
the  object  being  to  protect  the  injured  bones 
from  atmospheric  iutlueuces. 

Surgeons  are  now  becoming  familiar  with  the 
fact  that  considerable  depression  may  exist  in 
the  external  tablet  of  the  skull  without  the  in- 
ternal being  fractured — the  external  Layer  being 
driven  into  and  condensed  within  the  diploe. 
Also,  that  both  tablets  may  be  depressed,  com- 
pressing the  brain,  without  causing  harm  at  any. 
subseipient  period.  Observation  has  multiplied 
these  cases  to  such  an  extent  as  to  modify  the 
entire  treatment  Of  head  injuries.  Although  the 
cranial  cavity  is  filled  with  brain,  its  contents 
am  continually  undergoing  changes,  from  the 
dkcessUre  vascularity  of  the  brain  substance,  and, 
also,  from  the  free  communication  which  exists 
between  the  tluid  filling  the  ventricles  and  the 
venous  plexi  which  abound  in  the  brain.  By 
diminishing  the  blood  and  water  in  the  brain, 
accommodation    can    be    made   for  the  depressed 

bone. 

A-  a  general  rule,  in  gunshot  wounds,  with 
depression  of  fragments,  no  remarkable  symp- 
tom-  exhibit    themselves,  until    there   is  a  deter- 


-I'll  TUKATMKNT    "('    KUA<TMU.    "1     »KIM 

munition  of  blood  to  the  ) i « :i«  1  from  reaction, 
brought  "ii  by  mental  or  bodily  excitement.  Ra- 
tional practice  \v<>ul<l  lead  us  to  combat  the  ten- 
dency  t<>  congestion  bj  rest,  quiet,  cold,  revulsives 
and  venesection,  rather  than  by  the  trephine, 
which  experience  hat  Bhowii  t<»  be  unprofitable. 
Opium  is  now  seed  with  much  greater  freedom 
in  the  treatment  of  injuries  of  the  head  than 
formerly;  and,  when  administered  with  discre- 
tion, will,  to  a  certain  extent,  take  the  place  <>t" 
trephining.  Whenever  the  patient  is  restless, 
.sleepless,  and  irritable  with  delirium,  should  the 

face    not     he    red.    nor    head    hot.   it    can    lie    used 

with  safety  and  benefit. 

When  suppuration  is  established  in  the  wound, 
and  granulations  commence  to  form,  those  por- 
tions of  bone  which  cannot  he  saved,  will  gra- 
dually become  detached  and  will  escape.  A 
tendency  to  bleeding  in  the  granulations  of  the 

WOUnd     is    an     indication    that    the     fragments    of 

bone    have    become   loose,   and   are   ready  to   lie 
removed.      This    symptom,  which    is    a    valuable 

one,    must    he    noted. 

7'A.  fourth  variety  of  injury  to  >/"  /■<>></.  where  <> 
compound  fracture,  with  depressed  fragments,  is  <■<,<!- 
nectcd  with  symptoms  of  compression,  is  a  very  seri- 
ous accident,  and  is  the  only   variety  of  compli- 


TREPHINING   NOT  REQUIRED   IN   HEAD   INJURIES.     301 

cated  head  wound  in  which  surgeons  consider 
instrumental  interference  called  for.  Even  in 
this  instance,  the  propriety  of  trephining',  as  a 
rule,  is  doubted  by  many  of  large  experience, 
although  no  doubt  exists  that,  in  some  cases, 
immediate  relief  lias  followed  the  lifting  of  the 
depressed  bone.  It  is  said,  that  the  successful 
treatment  of  such  eases  will  depend  more  upon 
the  condition  of  the  brain  and  membranes  than 
merely  upon  the  depression.  Should  these  be 
lacerated,  or  in  any  way  injured,  inflammation 
will  sooner  or  later  show  itself.  The  operation 
of  trephining,  under  such  circumstances,  would 
in  crease  the  local  irritation,  expose  the  injured 
li>sues  to  injurious  atmospheric  influences,  and 
hasten  on  a  violent,  and  usually  fatal,  inflam- 
mation. 

If  the  brain  and  membranes  lie  not  injured, 
then  ii  i>  said  that  the  brain  will  soon  become 
accustomed  to  the  pressure;  and,  although  in- 
sensibility may  continue  for  hours,  days,  or,  as  in 
many  instances  of  ultimate  recovery,  for  weeks, 
the  symptoms  of  compression  will  gradually  pass 
off.  By  not  using  instruments,  the  surgeon  has 
the  satisfaction  of  knowing  that  he  has  not 
increased  the  local  trouble  by  a  serious  opera- 
tion.    Th<    removal    of    the    symptoms   of   com- 


302    TREPHINING  NOT  REQUIRED   IN   lll.\l>   IN.IfHlKS 

pression  being  very  gradual,  excessive  reaction 
is  not  likely  to  follow;  and  as  m>  air  lias  been 
admitted  t<»  the  effusions  beneath  the  skull,  the 
probability  <>f  suppuration  will  he  much  dimin- 
ished. When  effusions  have  taken  place,  the 
depressed  bone  acta  as  a  covering,  excluding  air 
with  its  injurious  chemical  influences.  Fluids, 
uncontaminated  by  decomposition,  can  In-  ab- 
sorbed. When  the  skull  is  opened,  and  the  free 
admission  of  air  is  permitted,  suppuration,  with, 
perhaps,  pyaemia,  is  prone  t<>  occur. 

Stromyer,  who  is  one  of  the  highesl  authori- 
ties on  gunshot  wounds  of  the  head,  and  who? as 
sargeon»in-chief  of  the  Scbleswig-IIolstein  army. 
bad  every  facility  for  studying  his  favorite 
branch  of  Burgery,  gives  us  as  the  resull  <>r  Ms 
experience,  observation  and  study,  thai  the  tre- 
phine can  be  abandoned  in  military  surgery.  In 
a  supplement  to  his  work  on  Military  Surgery, 
recently  published,  he  states:  "  that  in  military 
surgery,  trephining  is  never  needed. — When  the  ease 
i«  §e  severe  as  to  require  the  trephine  in  gun- 
shot wound-,  the  patient  will  die  in  spite  of 
it."  In  the  last  two  campaigns,  in  which  he 
had  charge  of  tfie  army,  he  has  not  trephined. 
Loeffler,  a  distinguished  Burgeon  in  the  Prus- 
sian   Service,    who    has   published    one    of   the    hest 


TREPHINING  NOT  REQUIRED  IN  HEAD  INJURIES.    303 

books  of  instruction  for  military  burgeons,  after 
acknowledging  Stromyer  as  the  master  in  all 
relating  to  the  treatment  of  gunshot  wounds 
of  the  head,  endorses  His  views  in  opposition  to 
trephining. 

McLeod  gives  the  following  as  the  Crimean 
experience:  vk.\s  to  the  use  of  the  trephine  — 
the  oases  and  time  for  its  application — less  differ- 
ence of  opinion,  I  believe,  exists  among  the 
experienced  army  surgeons  than  among  civil- 
inns:  and  T  think  the  decided  tendency  aiflong 
them  is  to  endorse  the  modern  'treatment  by 
expectancy.'  and  to  avoid  operating  except  in 
rare  eases.  In  this,  T  believe  they  judge  wisely: 
for  when  we  examine  the  question  carefully,  we 
find  that  there  is  not  one  single  indication  for 
Having  recourse  to  operations;  which  cannot,  by 
the  adduction  <>f  pertinent  cases,  be  shown  to  be 
often  fallacious."  HeWCtt,  in  a  series  of  lectures 
on  injuries  of  the  head,  published  in  the  Medi- 
cal Times  and  Gazette  for  1859,  which  form  the 
moet  complete  treatise  extant  on  the  subject,  is 
equally  adverse  to  the  trephine.  Guthrie,  Cole, 
and  Williamson,  in  their  reports,  equally  confirm 
the  dangers  of  the  trephine;  and  the  great  fatality 
accompanying  its  use. 

The    entire    records    of    the    science    mav   be 


,,n  1  FOREIGN    BODIES    IN    BRAIN. 

searched  in  vain,  to  tind  a  duplicate  series  of 
successful  cases  to  that  reported  by  Stromyer. 
of  forty-one  cases  of  fracture,  with  depression 
from  gunshot  wounds,  in  many  of  which  it  was 
probable  that  the  brain  and  membranes  were 
injured,  only  seven  died  —  all  the  rest  recovered. 
In  only  one  case  was  there  any  operative  inter- 
ference, although  signs  of  secondary  compression  ap- 
peared in  several.  The  antiphlogistic  treatment, 
carefully   carried  out,  was  alone  adhered  to. 

No  surgeon  dan  doubt  that  the  operation  of 
trephining  has  cost  many  a  man  his  life,  and 
although  many  cases  have  recovered  after  the 
operation,  it  is  a  question  whether,  in  the  ma- 
jority of  cases,  more  rapid  recovery  would  not 
have  been  obtained  without  it. 

When  symptoms  of  compression  ensue  in  the 
course  of  treatment,  continue  the  steady,  onward 
use  of  antiphlogistic  remedies.  At  this  junc- 
ture, many  surgeons  recommend  calomel  pushed 
to  salivation,  which  sonic  state  to  he  synonymous 
with  salvation.  There  is  no  unanimity,  however, 
on  this  head  ;  the  modern  tendency  is  to  treat 
such    cases   without  the    use   of    mercury. 

When  bails  penetrate  or  perforate  the  cra- 
nium, the  detached  pieces  <>f  bone  are  driven 
before  the  hall   into  the  substance  of  the  brain. 


FORKIGN    BODIES    IN    BR  A IX.  305 

The  resistance  which  the  ball  meets  changes  its 
course,    and   glancing   from    the   depressed   fragt- 

ment,  it  takes  a  different  direction  —  burying 
itself  in  the  brain  at  some  distance  from  tin; 
piece  ot  bone.  In  by  far  the  majority  of  cases, 
deatli  is  instantaneous,  or  soon  follows  the  re- 
ceipt of  injury.  There  are,  nevertheless,  a  lew- 
exceptions  to  this  rule,  in  which  the  patient, 
recovering  from  the  shock  and  sequelae,  lias 
carried  the  ball  or  other  missile  in  his  brain 
for  rears;  and,  eventually  dying  of  some  disease 
unconnected  with  the  head,  an  autopsy  revealed 
the  ball  embedded  in  the  brain,  and  surrounded 
by  a  mass  of  lymph.  Of  ninety-one  cases  of 
penetrating  and  perforating  gunshot  wounds  of 
the  head  which  were  admitted  into  hospital  in 
the  Crimea,  all.  without  exception,  proved  fatal. 
When  the  openings  are  examined,  it  will  be 
found  that  the  ho].'  made  in  the  outer  tablet  is 
more  or  less  smooth,  whilst  the  orifice  in  the 
inner  tablet  is  much  more  extensively  fractured, 
and  usually  much  spiculated.  This  condition  of 
the  orifices  is  owing  more  to  the  direction  of 
the  blow  than  from  any  supposed  brittleness 
in    the   inner   tablet  ;   i'o\\  should    the   ball   traverse 

from  within   outward,  the    reversed    condition    is 
found.      It   would  be  folly  to  attempt   tin'  search 


rO&l  I'.N    DOBXl  I    IN    HRAIN. 

after  such   foreign  bodies  for  r  1 1 « -  purpose  of  re- 

Eooving   them,    as   inch    :i    piece   af  meddlesome 

iv    would    ensure   a    fatal    issue,    whatever 

bopi    of  recovery    might  have   been  entertained.* 

Cole,  in  hi>  [ndian  Reports,  mentions  "that 
there  are  many  soldiers  now  doing  duty  in  ear 
ranks,  for  whom  (having  been  wounded  in  their 
heads  during  the  late  war)  the  medical  officers 
had  not  the  smallest  hope;  and  every  military 
Burgeon,  who  has  had  inndi  practice  in  the 
field,  has  learned  not  to  despair  so  long  as  lite 
remains."  The  thorough  probing  <>t'  Buch  i 
t"  satisfy  the  curiosity  of  a  Burgeon,  would  -nun 
have  destroyed  all  hope,  with  tin-  lite  of  the 
patient 

The  genera]  treatment  of  such  cases  should  in 
nowise  differ  from  that  laid  down  for  the  treat- 
ment of  lu-ad  injuries  in  general.  The  concus- 
sion and  compression,  which  arc  well  marked 
and  alwavs  present,  must  l>c  combated  by  using 
all  tin'  precautions  which  have  been  already 
pointed  out. 

we  might    now    sum  op,  in   a  few    words,  the 

•  On   one   occasion,  by   thi  bougie,    K:ir.>n    Larrev 

red        ball    wlii.-li    had    penetrated    ili<    forehead,  and,  trarel- 

mg   the  dura    mater,  had   lodged   al    and   under   the   occipital 

protuberance,   whence  ii    was    Buocessfullj    removed    bj   trephining. — 

•  lot  IfedietUi    0) tain  .  /'■• 


SUMMARY    OF    INJURIES    IN    HEAP.  307 

rational  and  successful  treatment  of  gunshot 
wounds  of  the  head.  In  concussion,  unless  there 
is  evident  sinking,  leave  the  case  to  nature,  and 
avoid,  studiously,  both  stimulation  and  venesec- 
tion. When  the  patient  is  restored  to  con- 
sciousness, should  imiiammation  of  the  brain 
threaten,  if  there  be  no  congestion  of  the  face, 
give  opium  to  allay  irritation.  Should  conges- 
tion be  evident,  use  the  antiphlogistic  treat- 
ment, locally  and  generally,  commencing  with 
venesection,  and  with  ice  applications  to  the 
head.  In  every  ease,  absolute  quiet  and  rest 
are  essential.  For  the  want  of  a  proper  sen- 
tinel at  the  door  of  the  ward  in  which  head 
injuries  are  being  treated,  many  cases  have  been 
tagfc  All  gunshot  injuries  of  the  head  are  seri- 
ous, however  trivial  they  may  seem,  inasmuch  as 
violent  inflammation  often  follows  slight  wounds; 
all.  therefore,  should  be  carefully  watched. 

Chronui  ostitis  or  periostitis,  resulting  from  gun- 
shot wounds,  possesses  no  peculiarity,  and  should 
be  combated  by  iodide  of  potassium. 


OH  A  P  T  E  R     VIII. 

Wounds  of  (hi    Fan — Fractures  of  the    I  "/'/"'•   <wni 
Lower  ./""' — Wounds  of  tht    Neck — T^argt  r 
nr,,l, I  //,,   perforating  ball — When  largi    arteries  ;,> 
>/■<    neck  "ft    divided,  th>    necessity  of  ligatmg  the 
bleeding   mouths. 

Wot  NDfi  -I  i  ill.  I1'  H  i:.  when  they  »1<>  not  im- 
plicate the  brain,  are  not  usually  of  a  ^«.i i« >uh 
character.  The  Bevere  cute  about  the  face,  made 
by  tin'  Bab  re  or  by  pieces  of  shell,  should  be 
treated  bo  as  to  obtain  adhesion  by  the  first  in- 
tention. The  lips  should  be  brought  together 
by  sutures,  and  eoid  water  dressings  will  com- 
plete tin1  cure.  The  excessive  swelling,  which 
accompanies  many  injuries  of  the  face,  impe- 
rially gunshot  wounds  and  bums  from  explosion 
•  '!'  powder,  is  readily  controlled  by  cold  water 
dressings.  It  inns  its  harmless  course,  mod- 
erated by  the  cold  applications,  and   subsides  at 

the  end  of  a  lew  days.  In  the  Italian  cam- 
paign. I  Baw  cases  in  which  Minnie  halls  had 
traversed   the  full    breadth   of  the    face,    passing 


WOUNDS    OF    THE    FACE.  o09 

through  each  malar  bone,  without  leaving  any 
injurious  sequelae.  The  rapidity  with  which  all 
wounds  of  the  face  heal  lias  often  boon  re- 
marked. 

The  most  common  injuries  to  the  face  from 
gunshot  wounds  are  fractures  of  the  upper  and 
lower  jaws.  Balls  often  become  embedded  in 
i  lie  soft,  spongy  bones  of  the  thee,  and.  if  not 
discovered,  are  in  time  discharged  spontaneously 
When  the  bones  of  the  face  are  struck  by  a 
grapeshot,  or  a  flattened  conical  ball,  there  may 
be  great  destruction  of  the  features,  followed  by 
shocking  deformity. 

The  senses  are  not  (infrequently  destroyed — 
sight  or  smell  being  often  impaired,  it'  not  com- 
pletely lost,  after  gunshot  injuries.  Where  the 
wound  has  been  Deceived  in  the  orbit,  the  loss 
of  vision  is  not  only  very  probable,  but  there  is 
great  fear  that  the  cause  producing  the  injurv, 
whether  it  be  a  ball,  bayonet,  or  a  sword  point, 
may  have  perforated  the  thin  plate  of  tin-  skull, 
and,  entering  the  brain,  may  induce  cerebral  in- 
flammation. Many  cases  of  apparently  trivial 
wounds  of  the   eyelids    have   terminated  fatally, 

and    an    autopsy    revealed    serious     injury    to    the 

anterior  lobes  of  the  brain  and  its  enveloping 
membranes.      Such     eases     should     be    carefully 


310  WOUNDS    OF   TOE    FACK. 

watched,  and  any  cerebral  symptoms  which  may 
arise  should  be  actively  met  by  the  antiphlogistic 
treatment,  headed  by  venesection. 

From  tbe  great  vascularity  of  all  the  struct- 
ures composing  tbe  face,  we  would  expect  to 
have  serious  hemorrhage  accompanying  all  inju- 
ries— for  controlling  which,  the  astringent  pee* 
parations  <>\'  iron  will  be  frequently  required. 
The  vessels  are  BO  numerous  that  the  direct 
application  of  ligatures  cannot  be  made.  In 
fractures  of  the  upper  jaw,  the  hones  are  always 
more  or  less  spiculated,  with  one  or  more  teeth 
loosened  or  completely  detached.  As  all  por- 
tions are  freely  Bupp'lied  with  blood-vessels,  union 
will  take  place  among  the  fragments,  even  after 
considerable  shattering  of  the  hones.  Unless  the 
fragments  are  either  completely  detached  or  hut 
slightly  adherent,  they  should  not  be  taken  away, 
hut  should  he  replaced  with  care,  as,  in  time, 
consolidation  may  lake  place,  and  very  little 
permanent  deformity  will  he  left.  Should  some 
of  these  fragments  die,  they  will  be  found  loose, 
often  as  early  as  the  sixth  or  eighth  day,  and 
should  be  removed.  The  cold  water  dressings, 
to  relieve  the  excessive  swelling,  with  an  eeesM 
sional  dose  of  salts,  is  the  only  medication  re- 
quired.    The  wound  in  the  face  should  he  closed 


FRACTURES    OF    BONES    OF   TflE    FACE.  311 

with  adhesive  plaster,  and.  after  careful  adjust- 
ment of  the  movable  fragments,  and  the  use  of 
cold  water  dressings  for  a  few  days,  the  case  is 
left  pretty  much  to  nature. 

When  the  soft  parts,  as  well  as  the  hones,  are 
crushed,  secondary  hemorrhage  frequently  recurs, 
as  the  sloughing  tissues  come  away.  Formerly, 
the  difficulty  of  restraining  this  loss  of  hlood 
was  so  great  as  to  require,  in  many  cases,  the 
ligation  of  the  main  vessels  in  the  neck.  AVe 
now  find  the  local  application  of  the  per-chlo- 
ride  or  per-snlphate  of  iron  an  efficient  remedy. 
Should  necrosis  follow  injuries  to  the  hones  of 
the  face,  the  dead  pieces  of  hone  should  he  re- 
moved as  they  become  loosened,  or  a  special 
operation  may  he  undertaken  for  ridding  the 
face  of  the   local   cause  of  trouble. 

Fractures  of  the  lower  jaw  are  not  a  rare 
accident  on  the  battle  field,  whether  caused  by 
shot  wounds  or  other  casualties.  At  times,  the 
entire  jaw  may  he  swept  off  by  a  round  shot, 
leaving  the  mouth  and  throa*t  exposed.  One  of 
the  most  fearful  cases  on  record  of  such  an  in- 
jury i>  one  in  which  the  entire  face  was  carried 
away  l>v  a  cannon  ball,  leaving  nothing  but  the 
skull  proper  appended  to  the  vertebral  column. 
The    opened    gullet    marked    the    former   >ite    of 


312       FRACTl  RES  OF  BONES  OF  THE  FACE. 

the  features.  The  patient  lived  ten  hours,  aud 
from  tin'  frequent  change  of  positiou,  and  the 
squeezing  of.the  hand  when  his  was  taken,  it 
was  thought  that  consciousness  remained  up  to 
the  time  of  death. 

The  surgeon  accompanying  the  transport  usu- 
ally sends  injuries  of  the  face  to  the  Held  in- 
firmary uutouched,  or,  should  the  lower  jaw  be 
broken,  applies  a  folded  handkerchief,  or  hand, 
under  it  to  support  it.  This  fracture  is  perma- 
nently put  up  at  the  field  infirmary  in  a  paste- 
hoard  splint,  well  padded  with  carded  cotton,  and 
secured  by  a  folded  cloth  or  double-tailed  band- 
One  hand  passes  over  the  vertex,  support- 
ing the  .jaws,  whilst  the  other  passes  from  the 
front  of  the  chin  behind  the  head,  and  then 
around  the  forehead,  where  it  is  secured  by  pins. 
Before  the  dressings  are  applied,  the  wounds 
should  have  been  examined  carefully  with  the 
finger,  and  all  perfect ly-detached  spiciilaa  of  hone 
should  have  been  removed.  The  surgeon  must 
be  prepared  to  meet* much  swelling  and  profuse 
salivatiou.  All  gunshot  injuries  to  the  hones  of 
the  face  being  compound,  suppuration  is  soon 
established,  and  the  secretion  of  pus  is  copious. 
It  will  add  much  to  the  comfort  of  the  patient, 
if  his   mouth   be  swabbed  out  daily  with  a  piece 


WOUNDS    OF    THE    NKCK.  313 

of  soft  rag  or  sponge  attached  to  a  thin  piece 
of  wood.  From  the  difficulty  in  swallowing, 
fluid  nourishment  must  be  prescribed.  "Flu1  con- 
stant thirst  of  those  wounded  will  be  relieved 
by  small  doses  of  morphine,  or  by  acidulated 
drinks,  made  either  with  diluted  nitric  acid  or 
Vinegar.  Injuries  about  the  face  are  very  liable 
to  erysipelatous  attacks.  The  treatment  by  the 
tincture  of  the  muriate  of  iron,  locally  and  gen- 
rally,  will    stop   its   progress. 

Wounds  of  iht  me/,-,  with  injury  to  the  numer- 
ous Large  vessels  which  course  through  this  con- 
stricted region,  arc  among  the  serious  accidents 
in  battle.  From  the  anatomy  of  this  region,  we 
would  suppose  that  a  missile  could  not  traverse 
tin'  neck  in  any  direction  without  destroying  some 
important  part.  We  find,  after  every  great  bat- 
tle, the  neck  perforated  by  balls  in  every  direc- 
tion, accompanied  by  violent  bemorrhages ;  yet, 
with  the  first  fainting  brought  on  from  shock 
and  loss  of  blood,  we  find  a  spontaneous  cessa- 
tion of  the  bleeding,  and  the  onward  progress  of 
tin'  case  becomes  one  of  continued  convalescence, 
to  perfect  cicatrization.  1  have  seen  conical  balls 
perforate  the  neck  antero-posteriorly,  entering  just 
above  the  sterno-clavieular  junction,  and  passing 
in  the  mid.-i.  it  not  through,  the  largest  vessels  of 
27 


;;  |  |  WOUNDS    OP   THE    NECK. 

the  body,  without  producing  a  fatal  hemorrhage. 
I  have  also  seen  them  perforate  the  throat  tateN 
ally,  on  a  level  with   and  just  hehind  the   angle 

of  the  lower  jaw.  Mid  a  cure  equally  follow.  Ii 
n  wonderful  how  the  great  vessels  escape-,  <»r  the 
rapidity  with  which  clots  form  and  the  wounds  of 
such  vessels  etose.  McLeod  reports  one  hundred 
and  twenty-etght  cases,  more  or  less  severely  in- 
jured in  the  neck,  with  but  four  deaths.  Many, 
to  be  sure,  die  on  the  battle  field  in  a  few  mo- 
ments after  receiving  a  serious  injury  to  the  large 
arteries;  but,  Undoubtedly,  many  also  recover. 

The  powerful  iron  styptics,  with  methodically 
applied  compresses  and  bandages,  arc  the  only 
local  remedies  applicable  on  the  battle  field,  as 
thi'  assistant  surgeon,  following  the  troops,  has 
neither  the  time  nor  conveniences  for  ligating 
the  bleeding  mouths  of  the  divided  vessel,  how- 
ever urgently  it  may  he  needed.  The  preeau- 
tions  which  were  urged  in  discussing  the  means 
of  arresting  hemorrhage  in  wounds  generally, 
must  here  he  carefully  applied  ;  ami  should  sec- 
ondary hemorrhage  occur,  notwithstanding  the 
pareful  application  of  the  iron  styptic,  the  safety 
of  the  patient  will  then  He  only  in  the  ligation 
of  both  bleeding  orifices :  the  anastomosis  of  the 
blood-vessels    in   the    neck    being  so  free  that  all 


WOUNDS    OF    THE    NECK.  315 

other  operations  will  be  futile,  and  the  patient 
will  perish.  A  ligature  upon  the  carotid  artery, 
at  a  short  distance  both  above  and  below  the 
wound,  has  been  reported  a  failure  in  control- 
ling a  hemorrhage,  whieh  was  only  checked  by 
dilating  the  wound  and  lighting  the  artery  at  the 
point  injured.  In  enlarging  the  wound,  the  in- 
cision will  always  be  made  parallel  with  the  axis 
of  the  neck,  so  as  to  avoid  injuring  important 
nerves  or  blood-vessels. 


CJJ  A  1'T  ]•;  !i     IX. 

Wounds  of  ihi  <  'lust—  Plesh  wounds — Effusions  within 
//,,  cavity  when  the  pleura  is  injured — Wounds  of 
th(  heart  or  lung  —  A  transfixed  Chest  does  riot 
necessarily  imply  a  /><  rforated  Lung  —  Diagnostic 
value  of  the  various  symptoms — Haemoptysis,  Dysp- 
noea, Collapse,  Emphysema —  Treatment  of  Chest 
wounds — How  inflammatory  complications  are  to  be 
combated — The  treatment  of  a  Fractured  Bib. 

Wounds  of  tii::  Chest,  when  taken  as  a  class, 
are,  perhaps,  the  most  fatal  of  gunshot  wounds. 
Many  are  shot  down,  and  die  more  or  less  rapidly 
on  the  hattle  held  from  internal  hemorrhage,  with 
its  accompanying  suffocation,  and  are  returned 
among  the  killed.  Fraser,  in  an  excellent  trea- 
tise on  chest  wounds,  based  upon  data  obtained 
in  the  Crimea,  states  the  mortality  to  have  been 
twenty-eight  per  cent,  of  all  chest  wounds,  and 
seventy-nine  per  cent,  of  those  in  which  the  lung 
had  been  injured.  The  Russian  Crimean  reports 
give  as  their  mortality  in  chest  wounds  ninety- 
eight   per  cent.,  which  is  sufficient  proof  of  the 


FLESH    WOUNDS    OK    TI1K    Clll'.ST.  :>17 

serious  character  bf  this  lesion.  The  danger  in 
wounds  of  the  thorax  is  from  visceral  complica- 
tions. Should  the  lung  be  severely  injured,  the 
case  usually  terminates  fatally. 

From  the  peculiar  formation  oi'  the  thoracic 
box  and  the  curve  of  the  ribs,  halls,  in  striking, 
are  often  deflected  from  the  straight  line,  and, 
after  a  longer  or  shorter  course,  escape  without 
having  penetrated  the  chest.  Often,  the  two 
openings  correspond  so  accurately  in  direction  as 
to  establish  a  strong  conviction  of  a  direct  pas- 
sage through  or  across  the  thorax,  when  the 
wound  has  been  but  a  subcutaneous  one  through- 
out: I  have  seen  an  instance  similar  to  reported 
cases,  iu  which  a  ball,  which  had  entered  the 
chest  just  below  the  left  armpit,  was  removed 
from  a  similar  position  in  the  right  side,  and 
although  it  had  apparently  traversed  the  thorax, 
no  inconvenience  was  experienced  ;  its  entire 
course  had  been  subcutaneous.  This  tortuous 
track  can  only  be  made  by  a  ball  striking  at  a 
considerable  obliquity.  Its  direction  is  generally 
indicated  by  a  reddish  or  purplish  line  under  the 
skiu.  which,  when  followed  by  the  finger  pressed 
on  the  surface,  imparts  a  crackling  sensation, 
caused  by  sir  in  ilie  cellular  tissue.  Such  inju- 
ries    arc    usually    simple,    and    require    but    little 


Slfl  -lloCK     l\    CHEST    INJURIES. 

treatment.      The   cold    water   dressing  Jills  every 

indication,  and  it-  application  for  a  few  days 
usually  effects  a  owe. 

A  great  amount  of  nervous  shock  often  accom- 
panies \<  ry  trivial  injuries  of  the  chest.  Many 
instances  are  mentioned  by  military  surgeons,  in 
which  balls  had  struck  articles  about  ilic  person 
of  the  soldier  —  tlic  breast-plate  of  a  cuirassier, 
or,  perhaps,  a  book  in  the  breast-pocket  of  a 
soldier's  coat — and  had  fallen  to  the  ground  with- 
out even  touching  the  skin,  yet  the  soldier  had 
been  knocked  down  breathless,  and,  in  boom 
eases,  did  not  recover  completely  from  the  shock 
for  dnys. 

Wlien  the  ball  has  penetrated  the  chest,  it 
may  course  for  some  distance  between  the  ribs 
and  the  pleura,  when  it  may  either  escape  from 
the  cavity,  and  be  found  under  the  skin,  or 
remain  capped  by  the  pleura.  Such  cases  may 
give  no  trouble,  or  pleuritis  may  ensue,  which  the 
rational  signs,  with  auscultation,  will  detect,  and 
an  antiphlogistic  course,  accompanied  with  the 
i'vvc  ii.-e  of  opium,  will  readily  subdue.  Opium, 
when  u-ed  in  large  and   frequently  repeated  doses, 

possesses  oiher  virtues  than  merely  allaying  pain 
and    quietiug    nervous    symptoms.      It    combats, 

directly,   intlammat ion,   and,   by  the  greal   control 


PKRFORATlXi:    WOUNDS    OF    THE    CIIKNT.  310 

which  it  exercises  over  the  brain  and  circulation, 
becomes,  in  the  treat  meal  pf  the  serious  sequelae 
of  wounds,  one  of  the  most,  if  not  the  most  valu- 
able remedy  of  the  materia  niedica.  When  given 
in  combination  with  nitrate  or  carb.  of  soda,  its 
nauseating  effects  are  counteracted. 

The  evil  which  the  surgeon  fears  from  perfo- 
rating wounds,  followed  by  inflammation,  is  that 
a  serous,  or  sero-purulent  effusion  may  rapidly 
accumulate  in  the  thoracic  cavity,  and  destroy 
the  patient  So  rapidly  is  this  fluid  formed,  in 
many  cases,  that  the  chest  has  been  known  to 
fill  in  twenty-four  pr  forty-eight  hours — the  fluid 
compressing  and  condensing  the  lung  against  the 
vertebral  column.  In  expanding  the  chest,  it 
will  lie  found  that  as  soon  as  a  thin  layer  of  fluid 
is  effused  into  the  cavity,  separating  the  lung  from 
the  thoracic  wall,  the  respiratory  murmur  becomes 
very  feeble,  and  will  altogether  disappear  when 
the  <;i\ity  ie  filled.  At  the  same  time,  respiration 
becomes  much  embarrassed,  with  marked  dysp- 
noea* Percussing  the  side,  will  now  give  a  dull, 
heavy  sound,  instead  pf  the  ordinary  clear,  sonor- 
ous one  of  health;  and  the  position  of  the  pa- 
tient, unless  the  cavity  is  filled  with  fluid,  must 
vary  the  sound  by  the  gravitation  ,,1'  the  serous 
collection.       The  lung  is  condensed   and  flattened 


PERFORATING    WOUNDS    <»F    TFIE    C1TV.ST. 

-t  the  vertebral  column,  and  is  temporarily 
impervious  to  air;  trader  n  long  continuan* 
the  pressure,  \\  will  become  permanently  consoli- 
i.  The  increase  in  the  circumference  of  the 
chest,  and  the  rulness  of  the  intercostal  B] 
with  the  absence,  to  a  greal  extent,  of  respiratory 
movements  upon  the  affected  side,  are  conspicu- 
ous svin|it(iiiis  of  a  distended  cavity. 

The  quantity  of  fluid  thrown  out  varies  from  I 
few  ounces  to  several  pints.  When  the  natural 
dimensions  of  the  cavity  are  not  sufficiently  ex- 
tensive to  accommodate  it.  it  forces  the  medias- 
tinum over  to  the  sound  side,  interfering  with  the 
action  of  the  healthy  lung,  whilst  an  encroach- 
rrienl  may  be  equally  made  upon  the  abdomen. 

When  the  surgeon  has  recognized  such  collec- 
tions as  rapidly  forming  in  the  chest  after  gunshot 
wounds",  accompanied  by  distressing  Bymptoms  of 
dyspnoea,  an  early  evacuation  will  be  required: 
Should  the  collection  be  purulent,  and  show  a 
disposition    to  point,  an  opening   for   the   escape 

of  the  fluid  should  be  made  at  the  point  which 
nature  indicates;  but,  in  cases  of  excessive  effu- 
sion, any  broad  Intercostal  space,  between  the 
sixth  and  eighth  ribs  on  the  right,  or  between 
the  seventh  and  ninth  on  the  left,  might  be  the 
point    selected.      The   instrument,  usually   a  trocar 


LTJNO    WOUND    IN    CUEST    TN.TIU1KS.  "21 

and  canula,  should  be  introduced  at  right  angles 
to  the  chest  and  near  the  upper  edge  of  t lio  11 1 » . 
toward  its  angle,  in  a  lino  continuous  with  tlio 
posterior  border  of  the  armpit.  As  this  punc- 
ture corresponds  with  the  lowest  portion  of  the 
cavity,  the  chest  can  be  perfectly  drained  through 
it. 

In  all  gunshot  injuries  of  the  chest,  the  most 
serious  complication  is  injury  to  the  Lungs  or 
heart,  and  it  is  often  difficult  to  detect  at  first 
such  lesions.  Notwithstanding  the  many  infalli- 
ble signs  laid  down  by  authors,  military  surgeons 
of  experience  inform  us  that  no  one  symptom  is 
sufficient  for  making  a  diagnosis.  When  the 
heart  is  injured,  although  instantaneous  death 
(\m'>  not  take  place  as  a  general  rule,  the 
wounded  man  lives  but  a  short  period.  The 
pericardium  soon  becomes  tilled  with  blond;  the 
action  of  the  heart  is  mechanically  impeded, 
and.  sooner  or  later,  depending  upon  the  size 
of  the  wound  and  the  facility  for  letting  out 
blood,  it  ceases  its  pnlsation.  Report*  of  eases 
are  not  very  rare  in  which  small,  oblique  incised 
wounds  of  the  heart  have  been  recovered  from  : 
and  even  gunshot  wounds  of  this  organ,  perfo- 
rating it>  cavities,  have  escaped  with  life.  When 
the  pericardium  is  perforated,  and  the  heart   not 


32'J  l.l   N<;    WOUND    IN    CHEST    IN.II  llll.s. 

i ii j u ihm I .  a  successful  result  might  be  obtained  by 
a   judicious    course    of  antiphlogistic    treatment, 

which   will   keep    down    inflammation,    with   ii-   I  I- 

fitsions  ai  lymph  and  serum. 

The  Lung  often  escapes  injury  when,  from  the 
position  of  thr  wounds  of  entrance  and  <>!'  exit, 
with  the  certainty  of  the  cavity  beiug  transfixed, 
the  natural  belief  would  lead  t<>  a  perforation  <«t" 
the  organ.  A  straight  line  between  tin-  wounds 
is  apparently  through  tin1  substance  of  tin- 
Lung,  but  the  ball,  in  perforating  the  rib.  had 
been  deflected  from  its  straight  course,  had  fol- 
lowed, perhaps,  the  inner  curve  of  tin-  chest, 
and.  meeting  with  some  resistance,  had  forced 
its  way  through  the  chest — either  appearing  un- 
der the  tough,  elastic  skin,  or  cutting  its  way 
out  without   having  touched  the  contained  organs. 

The  Lung  may.  on  the  other  hand,  be  severely 
injured  when  no  perforating  wound  exists.  A 
blow  by  a  spent  ball,  or  a  fragment  oi'  shell, 
may  make  a  very  superficial  wound  or  bruise  in 
ihe   skin,  and   yet    may   shatter  one   or   more   ribs, 

driving  the  spicule  into  the  lung,  lacerating,  to 

a  greater  or  less  extent,  its  substance.  Kven 
without  fracture  of  the  ribs,  the  concussion  or 
Mow  may  have  been  sufficiently  great  to  have 
caused  irreparable  injury. 


LUNG    WOUND    IN    CHEST    INJURIES.  0--i 

The    following   eases,    extract ed    from    8    Memoir 

on    Amputations,   by   Baron   Larrey.  will   exhibit 

die   extent    of   internal    injury  from    a    spent    liall 
without  external   indications  of  mischief : 

"■At  the  siege  of  lioses.  there  were  brought 
from  the  trenches  to  the  amhulance  that  I  had 
established  at  the  Village  of  Palace,  two  gumnerB, 
having  nearly  tlie  same  kind  of  wound:  they 
had  heen  struck  by  a  hall  oi'  large  calibre, 
which,  when  nearly  spent,  had  grafted  posteriorly 
their  two  shoulders.  In  the  first,  I  discovered  a 
slight  ecchymosis  over  the  whole  posterior  part 
of  the  trunk,  without  any  apparent  solution  of 
continuity,  lie  was  hardly  ahle  to  hreathe,  and 
spit  up  a  great  quantity  of  vermilion  and  frothy 
hlood.  The  pulse  was  small  and  intermitting, 
and  the  extremities  cold  ;  in  short,  he  died  an 
hour  after   the   accident,  as    I    had   prognosticated. 

I  opened  the  body  in  the  presence 'of  M.  Dubois, 

inspector  of  military  hospitals.  The  skin  was 
unhurt:  the  muscles,  the  aponeuroses,  the  nerves 
and  vessels  of  the  shoulder,  were  broken  and 
torn,  the  ftoapuls  fractured,  the  spinous  pro- 
•  of  the  corresponding  vertebra  of  the  hack 
and  the  posterior  extremities  of  the  neighboring 
rife*  fractured;  the  spinal  marrow  was  distended, 

the    parenchyma    of  the    lungs    toward    the    COITBS- 


HEMORRHAGE    IN    CHEST    WOUNUf 

ponding  points  «  eratad,  and   :i   considera- 

ble effusion  bad  taken  plaee  into  both  cavities 
of  the  thorax.  The  .—*•«-< > 1 1 « 1  gunner  died,  with 
the  Banie  Bymptoms,  three-quarters  of  an  hour 
after  his  etitranoe  into  thehospitaJ.  <  >n  opening 
the  body  the  same  mischief  was  perceived  as  in 
the  first." 

The  severity  of  the  Bymptoms  will  depend 
upon  ili«'  depth  of  the  injury  in  the  lung.  The 
deeper  the  lung  is  perforated,  the  larger  are  the 
blood-vessels  implicated  and  the  more  excessive 
and  rapid  tin-  hemorrhage.  It  is  on  account  of 
this  loss  thai  the  most  conspicuous  Bymptome 
arise,  viz :  hemorrhage,  collapse  and   suffocation. 

The  patient  may  Ik-  at  once  suffocated  by  a 
large  quantity  ■>!'  blood  filling  up  tin-  thorax,  and 
preventing    the    ingress    of   air    into    the    Uingflb 

Usually,    Wl I    |p;i->c>    from     both     month    and 

wound  :  that  from  the  month  is  frothy  and  timid. 
and    is    brought    it]>    liy    a    short,    tickling,    harass- 

Qough.  The  size  of  the  dark-colored  stream, 
poa ring  from  the  wound,  depends  upon  tin-  | ■< >~i - 
ii<>ii  of  the  orifice.  Wliere  the  orifice  n  situ* 
ated  1"\\  upon  tin-  cheat,  and  is  large  and  direct, 
the  effusion  into  the  cavity  escapes  freely  —  the 
symptoms  of  ool lapse  may  soon  appear,  but 
suffocation    is   prevented;  whilst    from   an    injury 


HEMORRHAGE    IN    CHEST    WOUNDS.  325 

in  Ike  upper  portion  of  the  chest,  particularly 
if  small  and  oblique,  the  thorax  may  till  with 
blood,  and  suffocation  becomes  imminent,  with- 
out much  external  loss.  The  danger  from  hem* 
orrhage  is  greatest  during  the  first  twelve  hours. 
and  is  pretty  well  over  by  the  second  day.  It 
may.  however,  continue  for  eight  or  ten  days, 
gradually  diminishing  in  quantity.  With  the 
flow  of  blood  from  the  wound,  air  often  escapes, 
and  the  two  symptoms  are  considered  unequiv- 
ocal proof  that  the  lungs  have  been  injured — 
their  absence  does  not  prove  the  contrary. 
•  The  mere  loss  of  blood  from  the  lung  is  ao 
certain  indication  that  the  organ  has  been  injured, 
as  bloody  expectoration  is  a  common  symptom 
of  blows  upon  the  chest,  and  may  accompany  the 
RIOS1  trivial  injury.  Fraser,  in  his  recent  work 
on  gunshot  wounds  of  the  chest,  places  a  less 
value  on  haemoptysis  than  do  other  military  sur- 
geons. Guthrie  considers  it  a  proof  of  lung 
wound:  so  does  Baudens,  MeLeod,  Btromyer, 
Ballingall  and  others.     Eraser's  experience  in  the 

Crimea    gives,    in     nine    fatal    eases    in    which    the 

lungs  were  wounded,  but  one  instance  of  lacniop- 

tysis,  ami   in   BCTetl    fatal   cases  in  which  the  lungs 

not    injured,   two   h:id    spitting   of  Wood.       In 

t\\c|\  of  recovery,  three   had   hiemoptysis. 


.;_'».  HYSI'VK.V    IN    ("HKST 

tie,  therefore.,  infers,  that  the  spitting  of  blood  it 
;i  very  deceptive  diagnostic  sitrn  of  lunsj  wound. 
When  it  is  rapidly  brought  up  by  mouthl'uls,  it 
an   important   -\  mpi  >m. 

The  discharge  from  the  wound  is  sometimes 
occasioned  by  injury  to  fche  intercostal  vessel; 
1  »u t  tliis  is  bo  rarely  the  case,  that  sicLeod  states 
tliat  he  neither  saw  nor  heard  of  an  instance' 
daring  the   Crimean   war. 

The  most  distressing  symptom  is  dt/xpncea, 
which  may  appear  soon  after  the  injury  has  »•»■ 
received*  or,  perhaps,  not  until  some  days  have 
intervened  ;    in  eertaia  eases   of  undoubted  fling 

injury,  it  may  UOl  have  heeii  present  at  any  time. 
This  symptom  is  sometimes  very  intense — from 
Etoral  or  otlier  causes — when  the  lung  is  not 
wonmleil.  sod  it  may  he  hut  slightly  marked,  ,,y 
even  altogether  absent,  when  the  lung  is  seri- 
ously implicated.  This  difficulty  in  breathing 
depends,  in  some  instances,  upon  the  direct  press- 
ure and  condensation  of  the  lung  by  air  or  hy 
fluids.       When     the     chot     has     heeli    opened    hy    a 

hall,  the  ludsg  does  not  collapse,  as  ia  generally 
supposed,  but,  it'  the  opening  u  sufficiently  large, 

can  he  veen  moving  lo  and  fro  ae;ain-t  the  tho- 
racic    walls    >imullaiuoii>|  v    with    respiration:    and. 

as  a  proof  i>(  the   continued  action  of  the  Lung, 


EMPHYSEMA    IN    CHEST    WOUNDS.  3^7 

and  its  inflation  with  air,  it  is  sometimes  found 
protruding  from  the  orifice,  forming  a  hernia  of 
the  organ.  Even  when  the  lung  has  been  com- 
pletely perforated,  it  does  not  necessarily  collapse, 
hnt  as  blood  ©scapes  into  the  pleural  cavity,  the 
lung  may  be  driven  hack  and  condensed  against 
the  vertebral  column,  with  all  the  accompanying 
symptoms  of  dyspnoea.  From  injury  to  the  lung 
and  continued  escape  of  air  into  the  pleural  sac, 
we  sometimes  find  similar  difficulties  in  respira- 
tion  induced. 

Emphysema  is  a  symptom  of  injury  to  the  lung 
upon  which  much  importance  lias  bees  placed. 
It  can  occur  under  any  circumstance  by  which 
air  is  admitted  into  the  pleural  cavity,  where, 
being  compressed  by  the  action  of  the  lnng  and 
walls  of  the  chest,  it  is  forced  ont  through  the 
wound:  hut  if  a  ready  exit  is  ao1  offered  for  its 
escape,  or  should  any  obstacle  exist  in  the  form, 
size,  or  direction  of  the  wound,  it  is  forced  into 
1 1 !<•  cellular  tissue.  Owing  to  the  free  commu- 
nication in  the  interstices  of  areolar  tissues,  it 
diffuses  itself  widely  and  rapidly.  Should  a 
perforated  wound   from  a  hall   or   other  weapon 

allow  air  to  enter  the  pleural  cavity.  Whether 
the   luii-     he     injured    of    not.    emphysema   might 

appear.      It    is    m.t    m    eMixma    after    gunshot 


:;_"*  COLLAPSK    IN    en 

wounds,  as  :i  free  exit  if  offered  to  the  cunteuts 
of  i  1m-  cavity,  h  ii  :i  much  more  common  ac- 
companiment of  oblique  punctured  wounds  by 
sword  poind  or  bayonet,  and  a l>» •  in  cases  ti 
fractured  ribs,  when  sharp  spieulse  of  bone  have 
abraded  the  surface  of  the  lung  and  allowed  air 
to  escape  from  tile  Air  tabes  into  the  cavity.  As 
it  is  found  either  with  or  without  lung  injury, 
il    cannot    be   ol'   much     value    in    diagnosis.      The 

injured  Lung,  in  gunshot  wouuds,  does  not  often 
permit  air  to  escape  for  any  length  of  time  from 
it>  wounded  surface,  as  an  immediate  extravasa- 
tion of  blood  into  the  bruised  tissue  closes  up 
she  air  tubes,  and  shuts  <>il  commuuicstiou  with 
the  cavity. 

Another    Bymptom    <>(   greal    value    i>   collapse, 
depending  upon  Loss  of  blood.     It  is  well  known 

that    all    the    blood   of   the   body   must    continually 

pass  through  the  Lungs;  and  should  the  vessels 
composing  the  parenchyma  of  this  organ  1»<'  ex- 
tensively opened,  the  loss  in  even  a  short  period 
must   he  excessive.      It    is  not    surprising,    there* 

fore,    that     the     patient     should    soon    become    cold, 

pale,  ami  faint — with  feeble,  small  and  irregular 
pulse,  and  with  rapid  tendency  to  syncope.  This 
is  natures  effort  to  check  further  Loss;  and  al- 
though   sometimes    successful,    often    c-ives    but 


VALUE  OF  SYMPTOMS  IN  CHEST  WOUND.\  329 

temporary  security.     The  surgeon  trios  to  induce 
this  condition   for  a   similar  purpose. 

From  consideration  of  the  above  symptoms,  we 
are  induced  to  believe  that  no  one  symptom  is 
pathognomonic  of  injury  to  the  lung,  hut  it  is 
rather  from  a  combination  o'{  phenomena  that 
any  certainty  in  diagnosis  is  attained.  The  im- 
mediate danger  and  intensity  of  the  symptoms 
will  depend  upon  the  depth  of  the  penetration. 
Where  the  chest  is  only  superiicially  wounded, 
although  the  force  of  the  blow  may  lie  sufficient 
to  produce  an  amount  of  shock  oi~  shorter  or 
longer  duration,  and  blood  may  he  expectorated, 
from  the  concussion  of  the  lungs,  the  symptoms 
will  be  trivial.  The  pain  of  the  bruised  tissues 
will  pass  oil'  in  a  lew  days,  and  with  it  all  the 
accompanying  symptoms.  When  the  chest  has 
been  opened  without  injury  to  the  lung,  heart, 
or  intercostal  vessels,  the  symptoms  are  also 
trivial;  and  unless  inflammation  of  the  pleura 
ami  subsequent  effusions  of  scrum  <>r  pus  should 
ensue,  the  case  will  equally  require  but  little 
treatment.  "When  the  lung  is  implicated,  and 
especially  when  severely  wounded,  other  symp- 
toms arc  niore  or  less  conspicuously  present. 

;i   after   the    reception  of  a   severe   wound, 
Mood  pours  from  the  injured  vessels  and   escape* 


o.;n  TRKATMENT    OF    CHEST    INJURIES. 

both  into  the  air  tubes  and  into  tin-  pleural 
From  the  tir  vessels  ii  is  brought  up 
and  expectorated,  in  greater  or  lest  quantity*  as 
haemoptysis,  whilst  it  flows  from  tha  exto  rnal 
wound  in  the  aide.  It'  the  openings  in  both  luog 
and  chest  be  free,  the  blood  escaping  is  min- 
gled with  air  when  the  patieul  coughs.  With 
the  loss  of  blood,  the  surface  becomes  cold  ami 
bedewed  with  ;i  eoW  perspiration;  the  pulse  ie 
weak  ami  tremulous,  becoming  more  and  mote 
enfeebled  until  syncope  comes  on,  which  tempo- 
can  ly  checks  the. excessive  bleeding.  Should  the 
orifice  in  the  side  oiler  an  imperfect  escape  to 
the  blood,  it  collects  in  the  pleural  cavity,  rap- 
idly encroaches  upon  the  lung,  which  is  forced 
back  against  the  spinal  column,  and,  by  com- 
pressing the  opposite  side  of  the  che6t  through 
the  mediastinum,  threatens  suffocation.  The  eyes 
protrude,  nostrils  expand  to  their  utmost,  the  arms 
arc  thrown  about  in  every  direction,  and  fright- 
ful struggles  for  breath  appear  in  every  feature- 
These  arc  the  cases  which,  it'  not  immediately 
relieved,  will  in  a  few  moments  terminate  fatally 
hv  suffocation. 

Tha  field  Burgeon,  in  transporting  those  wound- 
ed in  the  chest,  will  give  the  most  careful  atten- 
tion to  the  severely  wounded.     The  Bimple  cases, 


TREATMENT    OF    CHEST    INJURIES.  881 

requiring  no  immediate  attendance,  will  be  sent 
on  to  the  field  infirmary.  Although  the  wound 
has  evidently  transfixed  the  chest,  if  no  urgent 
symptoms  exist,  the  ease  is  also  carefully  con- 
veyed to  the  intiimarv,  or  even  directly  on  to 
the  general  hospital ;  hut  should  the  distressing 
symptoms  above  mentioned  follow  soon  after  the 
injury  has  been  received,  then  the  life  of  the 
patient  is  in  the  hands  of  the  ambulanee  sur- 
geon, and  should  he  ignore  or  neglect  the  ease, 
the  soldier  may  not  reach  the.  infirmary  alive. 
Notwithstanding  the  hemorrhage,  open  a  large 
vein  and  draw  away  blood,  if  possible,  to  syn- 
cope. The  safety  of  the  patient  depends  upon 
this  being  obtained;  as  in  the  interval,  when 
the  heart's  action  is  at  its  minimum,  but  little 
blood  will  be  driven  t<>  the  Langs,  and  a  dispo- 
sition to  the  formation  of  a  dot  may  plug  op 
the  bleeding  vessels.  Tke  dyspnwa,  and  not  t),c 
pulse,  will  be  the  indication  for  bleeding  in  lung 
wounds. 

'flic  patient  is  not  detained  on  the  field  to  sec 
the  effects  of  the  venesection,  but.  with  his  vein 
open.  i>  seal  on  to  the  field  infirmary,  accompa- 
nied l.y  the  surgeon,  or  by  an  intelligent  assistant. 
A-  MOD  .1  he  faints,  the  surgeon  at  the  field 
infirmary   removes   the    rough   field   dressing,    ex- 


■IK  1  OK    (Mil  ST    IN  JUKI  I 

amines  the  wound  with  the  finger,  and.  if  not 
sufficiently  large  to  permit  :i  thorough  search 
for  foreign  bodies,  where  such  are  suspected,  he 
dilates  it  with  ■  probe-pointed  bistoury. 

In  perforating  chesl  wounds,  unless  urgenl 
symptoms  of  dyspnea  arc  present,  the  general 
treatment  Is  of  the  expectanl  plan.  The  wound 
having  been  carefnlly  closed  with  diachylon, 
the  patieut  lies  on  the  wounded  side,  so  as  to 
throw  the  lung  against  the  ori&ce,  hopiug  tliai 
it  may  adhere  to  the  ohest  at  that  point,  and  so 
close  the  cavitgr;  he  also  finds  this  the  most 
comfortable  position.  He  ii  kept  quiet,  in  ■ 
dark  room  ;  all  excitants  are  avoided,  rigid  diet 
is  instituted;  veratrum  viride,  or  digitalis,  is 
given  to  control  the  action  of  the  heart:  opium 
ia  freely  administered  to  quiet  the  constant 
hacking,  tickling  cough,  and  iced  cloths  or  blad- 
ders are  applied  to  the  chest.  With  such  treat- 
ment and  careful  watching,  Beeing  the  patient, 
if  possible,  every  hour,  we  await  the  develop- 
ment of  symptoms.  The  accurate  closure  of  the 
wound  excludes  the  admission  of  air.  and.  to  a 
certain  extent,  prevents  emphysema,  and  also  the 
rapid  decomposition  of  the  escaped   Quids  in    the 

c;(\  it  V. 

It'   it    be    a  shot   wound,   with    a    single    orifice. 


TREATMENT    OF    CHEST    INJURIES.  333 

and  the  clothing1  bo.  found  perforated,  the  wound 
should  be  examined  for  foreign  bodies.  II'  found, 
extract  them;  if  not  detected,  then  close  the 
wound  carefully  with  a  strip  of  diachylon,  and 
apply  the  water  or  ice  dressing. 

The  search  tor  foreign  bodies  must  always  be 
made  with  the  finger,  and  should  never  be  pro- 
tracted. Should  nothing  be  found  after  a  mod- 
erate, intelligent  search,  close  tin-  wound,  and 
await  developments.  This  examination  should 
he  made  before  reaction  comes  on.  Should  we 
iim!  see  the  patient  until  he  is  icYerish,  all  exam- 
inations must  he  absolutely  forbidden  for  at  least 
eight  days,  until  the  reaction  has  subsided  and 
suppuration   well   established. 

It  is  well  known  that  balls,  etc., — even  pieces 
of  clothing — have  been  found  encysted  in  the 
lungs  years  after  they  had  been  deposited;  and, 
in  -lime  instances,  these  articles  have  been  ex- 
pectorated,  after  long  intervals,  during  a  severe 
spell  of  coughing.  Although  always  desirable 
that  these  he  removed,  a  prolonged  search  may 
entail  BUch  an  amounl  of  injury  as  to  destroy 
all  hope  of  saving  the  patient,  when  the  pres- 
ence of  the  foreign  body  would  not  have  been 
necessarily  incompatible  with  life  or  even  health. 
JJesides.    when    suppuration    is    veil    established, 


:;..  I  IBtATMt.M    Oi     1'llt.Vr    I.NJUU     - 

\vr  have  a   second    and    mucli    hotter   opportunity 
for  a  careful  examination,  without    mud 
doing  injury. 

S  ouid  the  gradual  accumulation  of  blood  in 
the  cavitj  <>l  ike  chest  « :* u^«-  tlyspnaa,  tin 
gee  1 1 1 : i \  require  opening,  i<>  allow  tin-  fluid  to 
escape  and  relieve  the  pressure  upon  tin-  lung. 
J  ii  drawing  oft'  the  contents  of  the  chest,  if 
syncope  threatens,  we  close  the  opening,  and 
await  another  opportunity.  Tin-  collection  is 
retained  in  certain  cases,  when  no  dyspnu'a  ex- 
for  the  purpose  of  retai'ding,  and  dually 
controlling  the  bleeding,  by  pressure  upon  the 
Lung  and  its  injured  blood-vessels.  After  the 
third  or  fourth  day,  the  tendency  to  hemorrhage 
having  ceased,  and  the  wound  having  all 
commenced  to  suppurate,  the  adhesive  plaster  ia 
removed,  aud  the  eftusion  is  allowed  to  escape. 
If  air  has  been  admitted  into  the  cavity,  the 
exuded  blood  has  decomposed,  and.  mingled  with 
serum  and  pus,  makes,  for  the  first  few  days,  ;i 
copious  and  very  offensive  discharge  Gradually 
the  escaping  lluid  loses  its  dark  color  and  oft- 
tensive  uiell,  and  assumes  the  appearance  of 
healthy  pus.  (formerly,  much  care  was  taken 
to  favor  the  flow  of  fluids  from  the  chest,  and 
dilation  of   the  wound  was  the   recognized  rule; 


TREATMENT    OF    CI}EST    INJURIES.  335 

now  the  opposite  treatment  is  the  one  urged,  to 
exclude  air,  and,  if  possible,  retard  decomposi- 
tion, as  this  deterioration  of  the  effused  iiuids  is 
more  injurious  to  the  system  than  the  advanta- 
ges obtained  by  their  ready  escape,  From  this 
time  onward,  simple  water  dressing  will  be  the 
only  loeal   treatment  required  for  the  wound. 

If  the  orifice  from  a  punctured  wound  has 
healed,  with  escaped  blood  remaining  within 
the  chest,  the  collection,  if  small,  should  be  ig- 
nored, as  it  will  gradually  he  absorbed;  but  if 
the  extravasation  be  extensive,  particularly  if  air 
had  previously  entered  the  cavity,  it  must  be 
withdrawn  through  a  puncture  made  at  the  most 
dependent  portion  of  the  chest.  This  operation, 
unless  called  for  by  urgent  or  distressing  symp- 
toms, should  in  no  ease  he  hastily  performed,  hut 
should,  on  the  contrary,  be  delayed  as  long  as 
possible. 

huring  the  treatment  of  perforating  wounds 
of  the  chest,  dyspmea,  whenever  urgent,  should 
always  be  removed  by  the  Lancet,  the  venesec- 
tion to   he   repeated   as  frequently  as   called   tor 

hy  threatened  suffocation,  unless  this  symptom 
he  clearly  traced  to  pent-up  fluid,  when  opening 
the  wound  or  enlarging  it,  to  permit  a  ready 
escape,  will  remove   the  oppression  of  breathing. 


:;:;.; 


1  Rl    VI'VI  NT    OF    -III  -I      INJl 


Prompt  and  repented  venesection,  followed  by 
such  remediei  a^  will  control  the  action  of  the 
heart,  will  also  be  required  to  cheek  hemorrhage, 
which  is  a  common  cause  of  death  in  such  in- 
juries, and  will  alone  diminish  the  number  of 
victims  of  chesl  wounds.  In  collapse,  we  have 
alreadj  recognized  a  valuable  aid  for  cheeking 
hemorrhage,  and  its  remediable  advantages  should 
be  appreciated.  A-  a  symptom,  ii  must  be  care- 
fully watched,  and  should  it  threaten  t<>  stop  the 
action  of  the  heart,  external  stimulation  must 
be  freely  need;  but  the  internal  stimuli  must  be 
administered  only  in  small  quantity,  and  with 
;it   caution. 

WTien  the  immediate  dangers  have  passed, 
tin'  next  in  order  is  inflammation  of  the  lung 
and  pleura.  Neither  of  these  conditions  differ 
in  any  very  material  respect  from  the  idiopathic 
varieties  of  the  disease.  The  traumatic  pneu- 
monia is  sometimes  circumscribed  to  narrow 
limits,  and  its  caU8e  maw  to  a  certain  extent, 
modify  the  general  symptoms.  As  the  cause 
of  pleuritis  is  a  direct  injury  to  the  membrane, 
and.  in  the  majority  of  instances,  as  air  lias 
been  admitted  within  the  cavity,  the  efrusions 
which  accompany  the  inflammation  soon  become 
purulent,  and.   in    time,  false   membranes   of  con- 


INFLAMMATORY    COMPLICATIONS.  ';:>7 

tiderable  fthiokness  line  the  inner  surface  of  the 
ribs. 

The  treatment  for  either  pneumonia  of  pleu- 
risy, when  occurring  from  a  ganehol  wound, 
does  not  differ  from  the  treatment  of  the  dis- 
ease from  any  other  cause*  MacLeod's  experi- 
enee  is  in  favor  of  early,  active,  and  repeated 
bleedings,  with  cool  drinks  and  abstemious  diet, 
recognizing,  at  the  same  time,  however,  that 
many  excellent  recoveries  have  beet!  made  with- 
out recourse  to  the.  lancet.  Guthrie  uses  the 
lancet,  which  he  designates  the  first  and  most 
essentia]  remedy,  and  which  he  says  should  he 
resorted  to  in  every  case.  The  venesection, 
which  he  repeats  whenever  the  inflammatory 
symptoms  show  an  increase,  is  vigorously  fol- 
lowed by  large  doses  of  tartar  emetic  in  pneu- 
monia, and  calomel  in  pleurisy — the  object  being 
to    affect    the    ejums  as  soon    as  possible.      This    is 

the  treatment  of  the  old  school,  which  recent 
experience  does  not  uphold.  Guthrie  stum- 
"that  in  the  Crime;)  bloodletting  had  not  been 
-o  favorably  viewed,  nor  found  so  serviceable, 
nor  v,,  uecessary."  Fraser,  from  Crimean  expe- 
rience,  states  thai,  in  the  prevention"  and  re- 
duction  ><\'    inflammatory    action,    in    perforating 

Wound-    o|    the   c.]l6bt.    venc.-.-t  1  ion    j..   uol    demand- 


I  \  h  I.AM  MATiiRY    COMPLICATION." 

ed.     it   Bhould  only  be  used    when    the   pa 
lull,  strong,  and    labored — :»   condition   not   often 
lui-i   with.     When   the   heart   sud   pulse  are  both 

weak,  a  comn condition  alter  severe   wounds, 

the  abstraction  of  blood  will   occasion  a  complete 
prostration  of  strength,  and   may  be  fatal. 

There  is  no  reason  for  changing  the  plan  of 
treatment,  already  discussed  in  detail,  for  com- 
bating inflammation  following  gunshot  wounds, 
and  which  is  equally  applicable  to  chest  wounds. 
Even  when  the  lung  is  inflamed,  we  would  p*a- 
fer  the  mild,  expectant  and  antiphlogistic  treat- 
ment to  ill*'  spoliative.  Absolute  rest,  cooling 
beverages,  moderate  nourishment,  avoiding  over- 
stimulation, with  small  doses  of  tartar  emetic, 
veratfura,  of  digitalis,  with  the  liberal  ase  «'t' 
opium,  and  attention  to  the  intestinal  secretioiw, 
will  be  required  in  all  cases,  and  in  many  will 
Compose   the   entire    treatment. 

A  certain  degree  of  pleuritia  ie  expected  and 
desired  in  penetrating  lung  wounds,  to  establish 
adhesions  between  the  injured  lung  and  thoracic 
wall,  which  will  at  oner  isolate  the  injured  part, 
and  prevent  inflammatory  Bequelse.  As  gunshot 
wound-  do  not  elose  rapidly,  but  usually  Buppu- 
rate,  permitting  the  free  access  of  air  within  the 
thorax,  the  suppuration  will  he  profuse  and  long- 


PUS    IN    THORACIC    CAVITY.  830 

continued.  We  must  remembeT  this  in  the  treat- 
ment, and  not  use  depressing  agents.  When  the 
pleoritis  is  excessive  and  general,  both  false  mem- 
branes  and  the  sapid  accumulation  of  fluid  are  to 
be  anticipated.  If  the  external  wound  is  still 
open,  the  position  of  the  body,  which  is  very 
important,  will  allow  the  ready  escape  of  the 
effusion,  which  is,  at  first,  serous,  but  soon  be- 
comes purulent.  Position  and  constitutional  sup- 
port will  form  the  basis  of  treatment.  If  the 
]>u>  could  have  a  constant  outlet  for  escape,  and 
accumulation  within  the  cavity  could  he  pre- 
vented, the  false  ■  membranes  would  tie  the  lung 
to  the  thoracic  wall  at  a  much  earlier  period. 
and.  by  obliterating  the  pleural  cavity,  prevent 
further  discharge.  Should  the  wound  be  in  the 
upper  portion  of  the  cheat,  it  would  hasten  the 
cure  to  establish  a  counter-opening  from  the 
Mod    dependent    portion   of  the   cavity,  through 

which    the   drain   would    be   facilitated. 

The  chapter  on  the  treatment  of  suppurating 
wounds  lays  down  general  laws  for  counteracting 
the  injurious  influences  of  long-continued  sup- 
puration. 

Penetrating  wounds  of  the  thorax  oeeaiionallj 
remain  fistulous  lor  an  almost  indefinite  period— 
which  i.-«  caused  by  a  failure  of  general  adheaieu 


Silt  VCTlRKIi 


between  tin-  costal  mid  pulmonary  pleura;.  A 
kind  of  poucb  is  found,  lined  b\  it  false  mem- 
brane, from  which  a  purulent  lymph  is  continu- 
ally secreted.  Alter  empyema,  the  cheat  cott- 
bBacta,  the  wails  link  in,  the  diaphragm  rises  high 
on  the  affected  side,  the  spine  beenmes  contorted, 
nir  cntrrs  indifferently  into  the  lung,  Little  or  bjo 
respiratory  movements  are  seen  in  the  chest,  and 
a  portion  of  the  respiratory  apparatus  is  rendered 
useless  to  the  economy.  Usually,  the  long  train 
of  symptoms  terminate  fatally  in  phthisis.  Very 
Jew  oases  of  injury  to  the  lung,  from  gunshot 
wounds,  are  ever  restored  to  perfect   health. 

In  eases  of  fractured  ribs,  from  gunshot   injuries, 
the    hone    is    usually    spieulated,   and    some   of  the 

fragments  may  accompany  the  ball  in  it-  onward 
course.  Upon  examination  with  the  finger — exe- 
cuted with  great  caution  from  the  fear  of  push- 
ing the  fragments  iuto  the  chesl  and  converting 
a  simple  wound  into  a  perforating  wound,  which, 

in  itself,  is  always  a  serious  accident — these  irreg- 
ular    fragments,    if  detected,    should     be    removed, 

and.  if  accessary,  the  outer  wound  should  be 
enlarged,  to  facilitate  this  importanl  step.  The 
danger  is  not   so  much   from  the  breaking  of  the 

hone,  hut  from  the  displaced,  sharp  fragments, 
which    ma)   seriously   injure  the  pleura  and  Lung. 


rHACTI  nr.i>    Kll>  3-11 

When  removed,  and  the  sharp  edges  of  the  rib. 
which  turn  in  toward  the  cavity,  arc  excised,  the 
wound  should  be  closed  with  a  wide  adhesive 
strap,  and  cold  water  dressings  applied.  If  no 
symptoms  indicate  injury  to  the  lung,  a  broad 
hand  may  surround  the  chest,  to  control  the 
thoracic  movements  and  allay  the  pain  :  hut, 
should  any  oppression  in  the  breathing  show 
itself,  the  bandage  cannot  he  applied,  as  it  will 
increase  the  suffocative  feelings.  Where  the 
spicuhe  are  not  displaced,  a  broad  adhesive  strap 
is  the  only  local  apparatus  Required.  Necrosis 
of  the  rib  very  commonly  follows  a  gushot  frac- 
ture, and  may  require  a  subsequent  resection  for 
its   removal. 

When  (w  intercostal  artery  is  divided,  the  bleed- 
ing point  will  he  discovered  by  drawing  out  the 
lips  of  the  wound  with  a  tenaculum,  when  the 
i  should  be  secured.  All  military  surgeons 
agree  that  this  is  an  operation  more  frequently 
spoken  of  than  performed.  Many  of  extensive 
experience  have  never  seen   a   <-ase. 

When   foreign   bodies,   as   balls,   pieces  of  hone. 

cloth,   wadding,   etc.,   are   driven    into    the   pleural 

cavity,  unless  removed,  they  produce  fatal  results 

by   inflammation   and   exhausting  discharges.     A 

hall  can   he  sometimes  felt  by  the  patient, 


'.)\2  FRACTTRF.n    l: 

and  ita  movement*  often  detected  i>\  the  stethe- 
aoope.  Through  an  opeuing,  made  :it  tin-  most 
dependent   portion  of  tha  obeat,  the  foreign  body 

can  lie  removed  sueeessfnllv. 


(IT  AFTER    X. 

Wounds  of  Abdomen  —  Flesh  wounds  —  Never  probe 
perforating  wounds  of  the  abdomen,  and,  especially, 
never  attempt  to  search  for  foreign  bodies  which 
have  passed  beyond  the  abdominal  waUs — Sew  up 
intestinal  wounds — Dilate  wound  in  abdomen  when 
necessary  to  relieve  strangulation  and  to  facilitate 
reduction — Where  thx    forget   viscera  arc   injured, 

wry  <s  rare — Avoid  using  purgatives  when  (he 
intestine  is  wounded — Peritonitis  a  common  c 
of  mortality — Where  the  intestine  is  much  crushed, 
Lor,  it  out  of  th  wound,  or  excise  thx  crushed 
portion,  and  dosi  the  intestinal  wound  by  sutures — 
/,/  wounds  of  th   bladder,  continued  ust  of  catheter 

ntial. 

sir  Charles  Bell  has  remarked  { that,  although 
abdominal  wounds  bore  ;i  fair  relative  proportion 
to  other  wounds,  immediately  niter  a  battle,  I 
few  days  sufficed  to  remove  them — so  that,  by 
the  end  of  the  first  week,  there  was  scarcely  one 
be  be  -ecu.  \-  g  rule,  all  who  have  received 
wounds  of  the  lai-ire  ahdomiual  viscera  die  —  the 


344  SRWiita  up   vbdomim  \i.  trot  h 

exception,  of  restoration  t«»  health,  being  rarely 
met  \\ii!i.  Like  wounds  of  the  chest,  where  the 
abdominal  walls  are  not  perforated,  l>ui  the  en- 
track  of  the  ball  lies  in  the  thickness  of  the 
wound  is  Bimply  a  flesh  wound,  and 
should  be  treated  accordingly.  The  track  of  the 
ball  is  not  always  in  a  straight  coarse,  as  the 
muscles,  or  their,  tendinous  portions,  when  in 
action,  offer  sufficient  resistance  to  turn  tin-  bail. 
The  fascia  transversalis  is  said  to  >\\<>w  a  similar 
resistance  t"  oblique  sli.it. 

A  perforating  wound  <»!'  the  abdomen  is  equally 
dangerous  as  those  of  the  chest,  from  the  fear  of 
peritonitis,  which  is  apt  to  supervene.  It'  the 
perforation  be  made  by  a  Bword  or  bayonet,  or 
it'  there  Ik-  anj  prospect  of  healing  by  tin-  first 
intention,  tin1  wound  should  1"-  accurately  closed 
by  adhesive  straps  or  by  sutures.  In  sewing  op 
an  abdominal  wound,  many  recommend  that  the 
needle  should  not  pass  deeper  than  tli<'  super- 
ficial cellular  tissue  —  giving  as  q  reason  that 
when  tin-  muscles  arc  included  in  tin-  suture*, 
fehey  sometimes  draw  themselves  out  of  the  noose 
by  their  contraction,  whilst,  it'  tin-  peritoneum  be 
aleo  included,  peritonitis  is  much  more  likely  to 
occur.  Although  this  may  hold  good  tor  the 
peritoneum,   I    can  see    no    reason  why    attempts 


PROBING     VBDOMINAL    WiHNDS.  845 

should  not  be  made  to  cause  union  in  the  muscles, 
and,  therefore,  avoiding  the  peritoneum.  T  would 
include  all  the  tissues — even  to  the  transversalis 
fascia  —  in  the  suture.  When  this  is  done,  the 
cicatrix  will  be  tinner,  and  there  will  he  less 
probability  of  secondary  hernia — a  very  eommon 
accident   alter  injury   to  the  abdominal   walls. 

In  probing  abdominal  wounds,  the  only  object 
to  he  sought  by  the  examination  is.  whether  the 
wound  has  perforated  the  cavity  or  not  ?  From 
the  direction  of  the  track,  this  can  nearly  always 
be  determined.  As  in  any  other  gunshot  wound, 
the  use  of  the  silver  probe  is  very  dangerous,  as 
it  may  convert  a  simple  into  a  perforating  wound: 
whilst  with  the  finder,  or  a  <rum  bougie,  the 
course  of  the  wound,  should  it  be  a  flesh  wound, 
can  he  traced,  and  also  the  existence  of  foreign 
bodies  detected.  Should  we  find  that  the  open- 
ing transfixes  the  abdominal  wall,  our  examina- 
tion should  go  no  further  —  it  is  a  dangeroua 
amusement  to  satisfy  curiosity  at  the  expene 
such  irreparable  mischief  as  may  destroy  the  life 
of  the  patient. 

It'   the    Wound    lie  ;i    l;irv;e  olie.   &8   \\  hell    made    hy 

a  s:ibrc-h;i\  oner,  fragment  o£  a  shell,  or  Minnie 
ball,  a  portion  of  the  abdominal  contents  may 
protrude  from  the  wound.      When   tin-  ambulance 


:»4(»  SI.S  HI     I  HE    AHI»o\||  N 

surgeon   finds   »nrh    ;i  'i    the    field,   his  first 

duty  will  be  to  examine  the  protrusion.  It  it  be 
:i  portion  of  small  intestine  and  be  not  injured, 
Li  of  dirt.  :tnd  nil  < »t  1 1«- 1*  extraneous 
substances,  by  pouring  water  upon  it.  and, 
fully  returning  it  within  tine  abdomen,  closes  the 
wound  by  sutures,  it'  it  be  an  incised  wound,  or 
a  broad  Btrip  of  diachylon  ]>lastrr.  it'  a  gunshot 
wound.  He  then  administers  ;i  dose  of  morphine, 
;ui«l  sees  tliat  the  wounded  man  is  properly  trans- 
ported t<>  tin.-  held  infirmary. 

To  facilitate  the  return  oi'  the  protrusion, 
whether  it  be  intestinal  or  omental,  tin-  patient 
is  placed  upon  his  back,  with  tin-  thighs  drawn 
up  and  the  abdominal  muscles  relaxed,  when  the 
ambulance  surgeon  makes  steady  pressure  upon 
tin-  protrusion  in  the  direction  of  the  wound. 
The  bowel  must  la-  handled  \crv  carefully  —  no 
force  should  be  used,  or  so  mueh  injury  might 
be  inflicted  as  to  cause  tin-  rupture,  sloughing  or 
inflammation  of  the  protruding  organ.  The  bet- 
ter plan  would  be  to  encircle  tin1  protrusion  by 
tin-  fingers  clustered  together  as  a  funnel  or  cone, 
which  will  diminish  the  hulk  at  the  opening  in 
the  abdomen,  and  facilitate  its  return. 

If  it  be  found  that  tin-  mass  is  so  constrieted, 
bv    tin'   small    size   of  tin'   oiil'nc.    thai     the    return 


TREATMENT  OF  WOUNDS  OF  THE  ABDOMEN.    -17 

within  the  abdominal  cavity  is  impossible  with- 
out inflcting  injury  upon  the  bowel,  the  intestine 
should  be  drawn  to  one  side,  and,  using  ureal 
caution,  the  wound  should  be  enlarged  upward 
for  a  quarter  or  half  an  inch.  As  the  constric- 
tion is  rarely  in  the  peritoneal  wound,  but  usually 
in  the  muscles  and  fascia,  the  incision,  if  possi- 
ble, should  not  include  the  peritoneum.  Cutting 
upon  a  grooved  director,  or  using  a  probe-pointed 
bistoury,  will  diminish  the  dangers  of  wounding 
-nine  important  port  within,  whilst  enlarging  tic 
wound.  The  return  o\'  the  bowel  should  always 
be  effected  by  the  ambulance  surgeon  before  the 
ease  is  transported  to  the  field  infirmary,  inas- 
much as  the  crowding  of  the  wounded  at  the 
infirmary  may  be  such  that  several  hours  might 
elapse  between  the  receipt  of  injury  and  the  hos- 
pital examination  —  quite  long  enough  to  cause 
strangulation  of  the  intestine,  and  sufficient  to 
excite  either  inflammation  or  mortification  of  the 
protrusion,  usually  a  fata!  complication  in  abdom- 
inal wounds. 

The  early  return  of  the  protruding  intestine 
makes  the  ease  one  for  simple  and  successful 
treatment.  Be  satisfied  thai  the  intestine  has 
been  returned  within  the  abdominal  cavity,  and 
not  forced    under   the   sheaths  of  the  abdominal 


:;  to  tki  \  i  mi. vi   or  in  ii-i  in  m.  oroi  n mi. 

muscles,  where  it  would  strangulate,  unci  rapidly 
destroy  life. 

Should  the  case  not  !"■  seen  until  several  horn's 
had  elapsed,  the  intestine  should  be  equally  re? 
iiinictl  whether  it   boot  il  or  inflamed:  but 

when  gangrenous,  which  Is  recognize^  by  its 
greenish  ash  oolor,  Loss  of  polish,  its  flaccid  con- 
dition,-with  already  a  disposition  to  separation 
in  its  various  coats,  it  should  remaiu  withouf  the 
wound,  and  be  laid  open  bo  as  to  allow  its  fecal 
contents  to  1"'  evacuated.  Adhesions  rapidly 
form,  uniting  the  protruded  intestine  to  the  peri- 
toneum at  the  inner  orifice  of  the  wound.  This 
-lints  off  all  connection  with  the  peritonei 
cavity,  and  prevents  extravasation  of  feeal  mat- 
ter within  it.  It'  the  bowel  be  returned  in  ■ 
mortified  condition,  the  contents  of  the  bowel 
would  be  discharged  into  the  peritoneal  cavity, 
and   fatal   peritonitis  would   be  excited. 

Should  the  intestine  be  injured,  it  is  left  in 
situ,  covered  with  a  wet  or  oiled  cloth,  until  the 
wounded  soldier  reaches  the  field  infirmary,  when 
it  i-  closed  with  one,  two.  or  more  points  of 
interrupted  suture*  according  to  the  size  of  the 
openiii-- — a  stitch  being  placed  for  every  one- 
sixth  o!  an  inch  of  intestinal  wound.  The  ends 
of   the  suture  arc  cut   oil'  close   to   the   knot,  and 


TREATMENT    OF    INTESTINAL    WOUNDS.  o4t» 

the  whole  is  returned  with  care  into  die  abdo- 
men. A  line  cambric  needle  will  be  tin'  best 
instrument  for  sewing  up  intestinal  wounds,  as 
tin'  small  puncture  and  tine  thread  produce  but 
little  irritation.  In  passing  the  sutures,  do  not 
include  the  lining  mucus  membrane  in  the  noose, 
tor  if  this  he  allowed  to  pout  between  the  Lips 
of  the  intestinal  wound  it  might  interfere  with 
rapid  healing c  the  serous  or  peritoneal  layers 
should  be  brought  in  contact,  wben  union  rap- 
idly follows. 

If  a  large  dose  of  opium  bad  been  admin- 
istered on  the  battle  field,  or  as  soon  as  the 
patient  bad  arrived  at  tbe  infirmary  wbilst  await- 
ing his  turn  to  be  dressed,  the  peristaltic  action 
of  the  bowels  would  have  been  suspended,  and 
the  wounded  portion  of  the  bowel,  which  should 
always  be  tbe  last  portion  returned,  when  tbe 
hernia  is  extensive,  remains  within  tbe  abdomi- 
nal cavity,  in  immediate  contact  with  the  wound, 
and  to  this  point  it  soon  becomes  attached 
through  adhesive  inflammation.  Should  the  su- 
tures give  way.  or  Ihe  bowel  sk)Ugfa  from  the 
injury  which  it  had  received,  its  contents,  instead 
oi  being  thrown  into  tin'  peritoneal  cavity  where 
it  would  produce  fatal  inflammation,  on  account 
of  tli**  adhesions  of   ihe    bowel    near   an   external 


350  TREATMENT    OF    INTESTINAL    WOl'NhS. 

outlet,  will  escape  externally,  which  diminis 
materially  the  ri<k  run  by  the  patient.  The 
threads  used  in  closing  the  open  hilt  in  the  intes- 
tine either  escape  through  tin-  bowel  by  stool, 
or  we  discharged  through  the  abdominal  wound. 
In  examining  the  externa]  wound  when  no  pro- 
trusion exists,  should  we  find  an  escape  of  feeal 
matter— -which  proves  thai  the  bowel  has  been 
perforated — tin-  abdominal  wound  must  be  en- 
larged, and  the  wound  in  the  intestine  dosed  by 
suture.  This  is  the  only  expedient  for  saving 
life:  for  if  the  contents  of  the  bowel  are  allowed 
'  to  eseape  into  the  peritoneal  cavity,  a  fatal  issue 
niiist  be  expected.  The  dilatation  of  the  wound 
diminishes  the  risks. 

Should  the  intestine  be  extensively  injured. 
beyond  the  possibility  of  saving  it,  rather  than 
return  a  portion  of  bowel  within  the  abdomen 
to  mortify  and  destroy  the  patient,  it  should  be 
left  hanging  out  of  the  wound.  All  of  the  sound 
portion  o(  the  protrusion  having  been  returned, 
the  crushed  portion  is  enveloped  in  a  wet  or 
oiled  cloth.  The  peritoneal  coal  of  the  bowel 
will  form  adhesions  to  the  peritoneal  edge  of  the 
abdominal  wound,  the  outer  portion  sloughs,  and 
an  artificial  anus  gives  constant  eseape  to  the  fecal 
contents.     In  time,  thie  artificial  outlet  gradually 


TREATMENT    OF    INTESTINAL    WOUNDS.  361 

closes  by  a  spontaneous  effort  of  nature,  the  feces 
seeking  their  normal  passage,  or  an  operation  at 
some  subsequent  period  removes  the  deformity. 

In  examining  the  archives  of  surgery,  we  find 
coses  in  which  portions  of  the  intestines  have 
been  eut  oil"  the  cylinder  of  the  bowel  reunited 
by  sutures,  and  excellent  recoveries  obtained. 
These  experiments  have  been  tried  successfully 
upon  animals,  and  instances  are  met  with  where 
the  human  subject  has  been  saved  by  a  similar 
operation.  I  have  recently  had  under  my  care 
a  lunatic,  who,  some  months  since,  attempted 
suicide  by  opening  his  abdomen,  drawing  out 
his  bowels,  and  completely  severing  two  feet  ^[' 
intestine.  Dr.  Gaston,  of  Columbia.  S.  C,  who 
had  the  ease  under  charge,  brought  the  two 
open  ends  of  the  intestine  together,  and,  secur- 
ing them  by  carefully  arranged  sutures,  returned 
them  within  the  cavity.  The  patient  made  a 
perfect  recovery.  This  accident,  which  termi- 
nated so  successfully  for  the  lunatic,  suggests  an 
operation  for  a  crushed  intestine,  which  may  offer 
better  prospects  than  leaving  the  bowel  to  slough 
and  form  an  artificial  aims:  remove  the  injured 
portion,  secure  the  bleeding  ve<>e]s.  and  red  iee 
the  intestine  by  sutures,  treating  the  case  M  if 
an  incised  wound  of  the  bowel  had  alone  ex- 
isted. 


t 

'■'>■'-  I  KI.A  I  Ml   N  I      (»]      I  VI  1   -II   sAI.     \\  I 


Iii  nil  perforating  w.-u mi-  of  tin-  abdomen,  as 
we    cannot     tell,    in    1 1 » *  -    ab-  s\  mptoms, 

whether  the  intestines  have  been   injured  or  not. 
are    two    fundamental    rules    of    treatment 
never    to    he    forgotten,  and    which    arc    required 
in  every  instant 

1.  dive  opium  freely  and  frequently,  with 
the  double  object,  viz:  of  controlling  the  peris- 
taltic action,  which  alone  ran  prevent  extrsi 
lion  of  the  contents  into  the  peritoneal  cavity, 
and  tor  its  antiphlogistic  eftect,  to  equalize  the 
circulation,  allay  pain,  suspend  nervous  irritabil- 
ity, and   prevenl    inflammation. 

2.  A \  i >iil  the  use  of  purgatives. 

With  the  majority  of  physicians  who  have 
had  lmt  little  experience  in  the  treatment  o\' 
abdominal  wounds,  the  tir>t  impulse  is  to  see 
the  bowels  emptied,  and  hence  the  fatal  purga- 
tive is  eagerly  administered.  An  evacuation  ap- 
parently reassures  them  that  all  i-  right:  when, 
on  the  contrary,  all  is  very  wrong,  as  the  march 
of  the  case  will  soon  show  them.  This  is  a 
fatal  error,  which  the  utmost  after-care  cannot 
remedy.      For   three    <»r    lour   days    at    leasl    after 


COMPLICATIONS    OP    ABDOMINAL    WOUNDS.  353 

tin-    receipt   of   injury,   in    which    the    intestines 

ore  known  or  are  supposed  to  be  wounded,  ali- 
solute  rest,  the  most  abstemious  diet,  and  the 
libera]  use  of  opium  (one  grain  o€  gum  opium,  or 
its  equivalent  in  laudanum,  every  five  hours),  in 
connection  with  cold  water  or  iced  dressing,  will 
compose  the  entire  treatment.  If  the  patient 
t'ceU  uneasy,  an  enema  will  relieve  the  large 
intestines  and  add  much  to  his  comfort.  By 
the  fourth  day.  the  wound  in  the  intestines  will 
have  elosed  by  lymphy  effusion,  and  the  dangers 
will,  to  a  certain  degree,  have  subsided.  If  re- 
quired, a  doBe  of  Epsom  salts,  citrate  of  mag- 
nesia, or  castor  oil,  may  now  he  given,  although 
it  would  he  better  to  wait  one  or  two  days 
longer,  when  the  risk  of  reopening  or  disturb- 
ing the   wound   would   he   hut    Slight. 

If  peritoneal  inflammation  he  excited,  with  fe- 
brile reaction,  pain  greatly  increased  by  pressure 
over  the  ahdoineii.  and  more  particularly  in  the 
neighborhood  of  the  wound,  with  tympanitis, 
vomiting,  hiccup,  small,  quick  pulse,  and  anxi- 
ety of  countenance,  the  fears  are  that  lymph 
and  sero-purulent  matter  will  he  rapidly  thrown 
out.  gluing  coils  of  intestines  together  and  till- 
ing the  cavity  with  fluid.  To  check  this  rap- 
idly fatal  disorganization,  leeches  or  cups  should 
.'in 


854  COMPLICATIONS    OP    ABDOMINA1    \r<>i  \ 

be  applied  to  the  abdomen,  to  be  followed  by 
1  arcotic  or  turpentine  Btnpes,  or  by  i<-.«  blad- 
ders, which  are  bow  preferred,  or  by  blisters, 
whilst  opium  should  be  sriven  in  I  a  rare  ■ 
and  at  short  intervals,  [f  the  patient  be  young 
and  plethoric,  and  the  inflammatory  symptoms 
are  early  recognized,  the  lancet  might  be  used; 
lu;t  usually,  in  military  surgery,  this  remedy  is 
badly  borne.  Calomel  was  formerly  used  with 
tlif  opium,  and  was  considered  the  mam  depend 
enoe,  but  is  now  being  generally  discarded,  as 
all  advantages  gained  are  accredited  t<>  Ibe 
opium. 

Sometimes  in  a  [few  hours,  usually  at  tin-  end 
of  the  Becond  or  third  day,  collapse,  with  a  cold, 
sweating  skin,  ami  Feeble,  irregular  pulse,  bbowb 
ilif  ravages  which  the  Bvstem  lias  experienced 
from  the  peritonea]  inflammation,  ami  marks 
rapidly-approaching  dissolution,  h  is  rare  thai 
the  liberal  use  of  brandy,  with  carbonate  <<\'  am- 
monia, external  warmth  ami  synapisms,  rescue 
the  patient  at  this  advanced  stage;  although,  if 
given  when  debility  commences  to  show  itself, 
they  may  BUpport  the  patient,  ami  he  the  means 
of  saving  life.  When  the  swelling  of  the  ab- 
domen, and  the  dull  sound  which  percussion 
elicits,   shows   extensive   effusion,  the   abdominal 


COMPLICATIONS    OF    ABDOMINAL    WOUNDS.  6t>0 

wound  should  be  reopened,  and,  by  placing  the 
patient  in  a  proper  position,  the  effusion  be  al- 
lowed to  escape.  It  is  a  desperate  operation, 
but  has  been  known  to  save  a  tew  eases,  which, 
if  let't  alone,  would  have  certainly  perished  as 
those  do  upon  whom  this  operation  is  not  per- 
formed. 

In  gunshot  wounds  of  the  abdomen,  if  the 
missile  has  perforated,  it  would  he  madness  to 
prohe  the  abdominal  cavity.  We  must  imagine 
the  worst,  give  the  patient  the  benefit  of  these 
doubts,  and  bv  extreme  care  hope  to  counteract 
the  baneful  influences  which  foreign  bodies,  when 
remaining  in  tin'  abdominal  cavity,  always  exer- 
cise. The  ball  may  have  traversed  the  cavity 
and  embedded  itself  in  the  fleshy  walls,  without 
having  injured  any  organ  of  importance  in  its 
course;  the  absence  of  serious  symptoms,  as  the 

progresses,  can   alone   inform  us  on  this  head. 

from  the  physiological  effects  we  might,  at  times, 
trace  the  resting-place  of  the  ball.  When  par- 
alysis of  the  lower  limbs  follows  an  abdominal 
gunshot  wound,  we  might  infer  the  burying  of 
the  ball  in  the  vertebral  column,  or  an  injury  to 
the  nerves  of  the  extremity  as  they  emerge  from 

the  spine,  etc. 

Should  the  abdominal  wound  bleed   profusely, 


HEMORRHAGE    IN 

-  tares    of  lil 1    may    be    from    within    the 

cavity  from  injured  viscera,  or  may  be  caused  by 
division  of  the  epigastric  artery  in  the  abdomi- 
ual  walls.  If  tli. ■  hitter,  dilatation  of  the  wound 
will  expose  it.  and  the  vessel  should  be  Ligated. 
When,  from  the  former  sourer,  but  little  can  be 
done,  venesection  to  syncope  miglil  check  the 
flow,  and  the  formation  of  ■  ek>1  may  plug  up 
the  injured  vessel.  Seme  Burgeons,  knowing 
the  desperate  condition  brought  on  by  internal 
hemorrhage,  recommend  dilating  the  wound,  and 
shoiihl  it  he  found  that  hemorrhage  conies  from 
one  of  the  mesenteric  vessels,  the  artery  should 
be  Ligated.  The  position  of  the  external  wound 
will  as.-ist  us  in  forming  a  diagnosis  a>  to  the 
probable  source  of  the  hemorrhag  i 
recovery  are  recorded  where  the  wound  was 
dilated,  and  the  bleeding  vessel  iii  the  omentum 
SOUghl    and    secured. 

Where  some   of  the    large   viscera   or   blood-ves- 

sels  are  injured  in  perforating  abdominal  wounds, 

the  Bymptoma  are  much  more  marked  than  in 
intestinal  wound.-;  hemorrhage  at  once  takes 
place,  to  ;i  serious  amj[  often  fatal  extent.  Such 
wounded   are    often     found    dead   upon    the   battle 

field;    or    should    they    he   alive,    they    are   pale   ;ind 

cold,  with  anxious  countenances  and  intense  long- 


HEMORIUIAOK    IN     ABDOMINAL    WOUNDS.  oO  I 

ing  for  water.  This  insatiable  thirst  is  not  pecu- 
liar to  visceral  wound  or  to  nervous  shock,  but 
is  an  indication  of  serious  hemorrhage.  If  the 
wound  be  extensive,  they  never  rally  from  this 
collapse.  In  other  cases,  the  shock  may  permit 
the  clogging  oi'  injured  blood-vessels,  and  stop 
internal  bleeding.  Should  life  be  prolonged  until 
reaction  takes  place,  the  violent  inflammation 
which  is  lit  up.  either  from  direct  injury  to  the 
peritoneum  or  from  the  quantity  of  blood  in 
the  cavity,  usually  carries  off  the  patient  after  a 
period  of  intense  suffering. 

On  account  of  the  hemorrhage  and  subsequent 
inflammation  which  accompany  these  injuries,  all 
wounds  of  the  larger  abdominal  viscera  are  con- 
sidered nearly  necessarily  mortal,  as  the  excep- 
tional cures  are  very  rare.  When  the  external 
orifice  is  small,  the  position  and  direction  of  the 
wound  will  lead  us  to  suspeel  the  special  injury, 
and.  in  connection  with  persistenl  vomiting,  the 
ejection  of  blood  by  the  mouth,  by  stool,  or 
with  the  urine:  the  escape  of  special  secretions. 
as  bile,  urine,  or  feecee  by  the  wound:  and  the 
peculiar  pain  or  sensations  experienced  by  the 
patient,  will  be  our  chief  indications  in  deter- 
mining the  pari   injured. 

The  treatment  of  the-''  serious  wounds,  which 


um  M's   (MT   Tin:    BLADIN 

on  tlio  whole  is  >o  unsatisfactory,  is  similar  to 
that  required  for  perforating  wounds  of  the  cheat, 
with  injury  to  the  Lungs.  It  wen  Boon  after  the 
accident,  before  much  blood  baa  been  extrav- 
i.  and  it'  nervous  Bhock  is  not  present,  the 
patient  should  be  bled  pearly  to  syncope  for  its 
anti-hemorrhagic  effect,  and  then  opium  internal- 
ly. ;iik1  cold  locally,  with  absolute  diet,  should 
become  the  basis  of  treatment;  a  little  water 
or  small  pieces  of  toe  is  all  thai  is  required  tor 
the   first   two  or  three   days. 

In  wounds  of  the  kidney,  frequent  micturition, 
with  bloody  urine,  marks  the  injury;  whil.-t  in 
injuries  to  ifu  bladder,  bloody  mine,  or  rather  the 
age  of  dots  as  well  as  pure  blood  through 
the  penis,  is  the  diagnostic  sign — should  urine 
escape  from  the  wound,  it  is  equally  pathogno- 
monic. In  addition  to  the  course  already  laid 
down  for  internal  abdominal  injuries,  the  intro- 
duction of  a  large  gum  catheter  into  the  bladder 
through  the  penis,  through  which  urine  is  allowed 
bo  drain  away  as  fast  as  it  is  secreted,  will  prevent 
urinous  infiltration,  which  is  one  of  the  most  fatal 
complications  connected  with  a  wounded  bladder. 
The   catheter  should   be  introduced    on  the  Held 

of    battle,   and     should    be   worn     continuously    for 

four  or  five  days  until  adhesive  iuuammatioa  has 


WOUNDS    OP    THE    BLADDER.  359 

closed  the  torn  cellular  tissue,  and  shut  up  the 
avenues  into  which  the  urine  would  have  escaped. 
The  catheter  will  also  be  required  when  the 
sloughs  are  separating,  as  swelling  ol'  the  pails 
often  obstructs  the  readyflow  of  urine.  The  gum 
catheter  may  even  he  kept  in  from  the  com- 
mencement of  the  treatment  until  the  wound  is 
well  advanced  in  healing,  unless  it  excites  nuieh 
irritation,  when  it  may  he  temporarily  with- 
drawn. This  precaution  will  prevent  many  cases 
of   urinous  infiltration,   and   save  many   lives. 

When  the  nook  of  the  bladder,  or  the  prosta- 
tic part  of  the  urethra  has  heen  divided,  if  the 
catheter  cannot  he  introduced,  a  free  incision 
should  he  made  through  the  perineum  for  the 
evacuation  of  urine  and  the  discharges  from  the 
wound. 

Fortunate  it  is  for  men  going  into  battle  that 
the  excitement  under  which  the  troops  are  at 
that  time  laboring,  causes  a  continual  dropping 
from  the  ranks  to  urinate,  so  that  rarely  doee  a 
soldier  go  into  battle  with  his  bladder  full.  In 
this  physiological  fact  lies  the  safety  of  many  a 
man.  as  the  contracted   Madder  concealed  behind 

the  puhis.  in  the  cavity  ^\'  the  pelvis,  often  es- 
capes injury  from  the  passagi  of  a  hall,  which. 
wore  tiic  organ  distended,  would  assuredly  trav- 
erse it. 


i.NJl    UU    Of      1  1 1  h.     I.AK..1      I  N  !  I    - 

From  the  hattles  mi'  Ihill  Hun  and  Mann 
several  cases  of  vesical  injury  were  collected  in 
the  hospitals,  Borne  of  which  were  successfully 
cured.  Among  tliese  was  one  of  Bpecial  inter- 
est, in  which  the  ball,  in  traversing  the  pelvic 
i  antero-posteriorly,  transfixed  bladder  and 
rectum,  anterior  abdominal  wall  and  sacrum, 
which  was  recognized  by  the  escape  of  urine 
anteriorly,  and  urine  with  fecal  matter  through 
the  sacral  orifice,  as  well  as  urine  running  oft' 
by  the  rectum.  Jn  time  these  orifices  closed,  and 
the  patient  -was  discharged  cured. 

Injury  to  tin  large  intestines  arc  uo1  so  serious 
as  perforations  of  the  small.  As  the  large  bowel 
is  bound  down  iii  the  greater  pan  of  its  oourse, 
extravasations  of  their  contents  d<>  not  nec< 
rily  take  place  into  the  peritoneal  cavity;  and 
although  fecal  matter  escapes  externally  from  the 
wound,  and  high  inflammation,  with  profuse  sup- 
puration, usually  follows,  many  of  the  wounded 
eventually  do  well. 

Cases  not  unusually  occur  on  the  battle  field 
in  which  the  abdominal  contents  might  be  se- 
verely crushed  without  apparent  external  injury. 
it  is  the  toughness  and  elasticity  of  the  skin 
which  gives  rise  to  the  exploded  theory  of  the 
wind  of  a    ball   destroying   life;   and  such  cases 


INJURIES    OF    THE    LARGE    INTESTINES.  SCI 

as  those  we  are  now  considering  were  formerly 
brought  forward  as  instances  of  the  fatal  effects 
of  the  vacuum  following  the  wake  of  a  cannon 
hall.  Observation  has  shown  that  a  knapsack 
might  he  torn  from  the  hack,  a  hat  strtick  from 
the  head,  an  epaulet  from  the  shoulder,  or  a  pipe 
from  the  mouth,  without  leaving  a  trace  of  in- 
jury, whilst,  on  the  other  hand,  viscera  might  be 
reduced  to  a  jelly,  or  bones  crushed,  •without  a 
visible  bruising  of  the  skin.  It  is  the  hall  itself, 
and  not  the  wind,  which  produces  these  disor- 
ganizations. From  the  blow  o\'  a  spent  cannon 
hajl  or  fragment  of  a  shell,  the  liver  might  he 
lacerated,  intestines  torn,  hlood-vessels  opened, 
spleen  fissured,  or  kidney  ruptured,  without  an 
external  wound.  Severe  shock  and  collapse  mark 
the  extent  of  injury  received;  and  should  the 
patient  rally  from  this  condition,  which  is  rare, 
violent  inflammation  will  soon  destroy  lite.  Al- 
though we  follow  vigorously  the  treatment  laid 
down  above,  we  very  seldom  have  the  satisfac- 
tion of  saving  a  patient 

The  amount  of  destruction  effected  by  a  spent 
hall  is  often  surprising.  The  uninitiated  on  the 
battle  held  will  attempt  to  stop,  with  the  foot,  a 
cannon  hall  rolling  on  the  ground,  and  which  is 
jnsl  ahoiii  exhausting  its  force,  perhaps  with  only 


862    ^      1N.II   HIK>    "I      Till'.     I. AH". I      INTK>riN»> 

momentum  sufficient  t<>  carry  it  one  or  two 
farther,  yet  it  crushes  tin-  limb  pot  out  to  op- 
it.  Baudens,  in  warning  persons  to  avoid 
cannon  lulls,  however  plowh  they  may  be  roll- 
ing "ii  tin-  ground,  mentions  the  case  of  a  irifi i- 
adier  of  the  guard,  sleeping  on  his  side  on  the 
ground,  who  was  instantly  killed  hv  ;i  spent 
cannon  ball,  the  blow  from  which  luxated  the 
vertebral  column.  The  ball  came  with  <<>  little 
momentum  that  it  rolled  itself  up  in  the  hood 
of  the  soldier's  overcoat,  where  it  \v;is  found.  It 
was  just  about  to  Btop  when  it  struck.  One 
or  two  feet  further,  and  it-  entire  force  would 
have  been  exhausted. 


CHAPTER    XI. 

Injuries  of  the  Extremities  —  Compound  Fractures — 
Differma  of  treatment  in  the  upper  and  lower 
limbs —  Importance  of  am  early  examination,  and 
adoption  of  a  course  of  treatment  within  twenty- 
four  hours  after  tht  receipt  of  accident — Compound 
fractures  of  th  Arm  from  shot  wounds,  when  not 
implicating  joints,  do  not  require  amputation  ;  should 
the  blood-vessels  and  nerves  bt  crushed  with  the  bone, 
then  amputation  necessary — When  gunshot  fractures 
implicate  joints,  resection  or  amputation  is  the  only 
means  of  saving  life— How  resections  are  to  be  per* 
formed  —  Special  Resections  of  Shoulder,  Elbow, 
Wrist — Resections  and  amputations  of  the  inferior 
extremity — Primary  and  consecutive  'imputation — 
Frost  JUti — When,  and  under  what  circumstances^ 
amputations  should  be  performed — Modes  of  operat- 
ing, and  of  dressing  stumps — Chloroform  in  >>// 
st  ,-ious  opt  rations. 

As  the  major  portion  of  the  injuries  of  the 
extremities  are  merely  flesh  wounds,  these  will 
ii"i   require  to    be   again    noticed.     Those   which 


•'!''>!  1NJIIUKS    OK    THE    KXTHKMITI1 

we   will    dow    consider   are   such   as   involve  the 

hones,  joints,    or    important  .    ami    whiefa 

may  call  f<T  special  treatment  It  is  in  tlii>  de- 
partment that  conservative  Burgery  has  made  tin1 
greatesl  advances,  and  has  accomplished  so  much 
in  diminishing  mortality  and  mutilation.  Not 
that  amputations  will  ever  be  abolished,  tor  many 
can  be  saved  in  bo  other  way  than  by  the 
sacrifice  of  limbs ^  but  conservative  Burgery  has 
shown  that  the  constant  flourish  of  the  ampu- 
tating knife  is  not  the  way  to  obtain  the  greatest 
number  of  surgical  victories  in  times  of  war. 
imputations  must,  however,  ever  remain  a  sur- 
gical necessity;  and  he  who  removes  crushed 
limbs  with  the  greatest  skill,  and  saves  the  pa- 
tienl  by  successful  after-treatment,  will  ever  de- 
serve the  high  position  which  humanity  and 
philanthropy  will  bestow  upon  him. 

In  gunshot  wounds  of  the  extremities,  we  ftnd 
a  much  greater  vitality  and  resistance  to  injuries 
in  the  upper  than  in  the  lower  limbs,  which 
would  modify  the  treatment  <>\'  similar  injuries 
located  in  these  two  portions  of  the  body.  This 
depends  upon  the  greater  vascularity  and  freer 
anastomosis  in  the  arm  than  in  the  leg.  In  the 
more  liberal  supply  of  blood-vessels  and  nerves, 
we  find  the  source  of  sateh  which   enables  us  to 


COMPOUND  FRACTURE  OF  THE  EXTREMITIES.        805 

save   an    arm.    when,    for   a    similar   injury,    a    leg 
would   be  generally  condemned. 

The  most  common  accidents  of  the  extremities 
which  give  surgeons  the  greatest  annoyance  and 
require  the  most  careful  diagnosis,  prognosis  and 
treatment,  are  <-<>iitj><»/it<l  fractures,  Those  hate 
always  been  a  numerous  and  important  class  in 
military  BUrgery,  hut  have  become  doubly  so  in 
modern  warfare^  from  the  substitution  of  coni- 
cal shot  for  the  round  musket  hall.  This  projec- 
tile never  impinges  upon  a  hone  without  leaving 
frightful  traces  of  devastation.  Such  a  conical 
hall  very  rarely  remains  embedded,  hut.  acting 
on  the  principle  of  a  wedge,  it  splits  and  com- 
minutes the  hone,  driving  the  loose  spicuhv  in 
every  direction,  and  even  impaling  neighbor- 
ing soldiers  by  the  detached  fragments.  Cri- 
mean Burgeons,  who  have  had  many  opportu- 
nities of  observing  injuries,  from  every  descrip- 
tion of  missile,  in  referring  to  the  conical 
ball,  speak  of  their  effects  as  so  dissimilar  to 
those  of  round  hulls,  as  almosl  to  justify  a  clas- 
sification of  injuries  founded  upon  the  kind  of 
hall  giving  rise  to  them.  They  state  that  the 
longitudinal  splitting  of  the  bone  is  so  dexter- 
oii>l\  and  extensively  accomplished  by  the  coni- 
cal   hall   that,    while    only   a    small    opening    leads 


'■■''"'■        COMPOUND  FRACTVRF.  OP  THE  EXTRKMT1 

to  the  seal   of  fracture,   tbe  whole  shaft   may  be 

rent  from  end  to  end.  Fortunate  it  is  that  this 
extensive  splitting  or  Hssuring  of  the  long  bones 
iM'i  -  xtend  into  the  joints,  or  ili<-  i  •  e  for 
operation  would  be  much  nn>rc  numerous  than 
they  now  are.  The  epiphysis  of  the  bone  ap- 
pears not  to  transmit  the  force  of  cleavage,  as 
the  injury  most  frequently  Btops  at  the  junction 
<>i'  ilic  head  of  the  bone  with  its  shaft.  The 
successful  treatment  of  such  wounds  requires 
much  judgmenl  and  experience,  with  a  thorough 
knowledge  of  those  agencies  antagonistic  to  the 
healing  of  wounds,  and  which  belong  to  military 
surgery. 

When  a  bone  is  crushed  by  a  ball,  the  patienl 
is  conveyed  very  carefully  to  the  field  infirmary; 
or,  if  it  can  be  done  withoul  delay,  to  the  gen- 
eral hospital,  where  the  treatmenl  commences. 
On  the  field,  the  ambulance  surgeon  can  do 
nothing  bu1  administer  a  dose  of  morphine,  and 
secure  the  limb  to  a  rough  splint  to  facilitate 
transportation.  For  a  fractured  clavicle,  scapula 
or  humerus,  the  arm  is  bandaged  to  the  chest, 
which,  on  the  battle  field,  answers  the  purpose 
of  a  temporary  splint  :  for  a  crushing  of  the 
forearm  or  hand,  the  arm  is  laid  upon  a  board 
splint,   and    slung  from    the    neck.      If  the   splint 


COMPOUND  FRACTURE  OF  THE  EXTREMITIES.        3G7 

is  not  at  hand,  the  sling  made  of  a  handker- 
chief must  answer  until  the  wounded  man  can 
be  better  attended  to:  it  being  understood  that 
a  wet  or  greased  cloth  is  always  put  over  the 
wound  for  its  protection  during  the  transpor- 
tation. 

When  he  arrives  at  the  hospital,  the  limb  is 
carefully  examined.  The  external  wound  may 
give  no  indication  o(  the  extent  of  internal  in- 
jury. When  ihe  linger  is  introduced  and  the 
wound  carefully  explored,  the  degree  of  crush- 
ing will  he  ascertained,  and  the  question  at  once 
proposes  itself:  what  course  shall  we  pursue? 
Shall  we  attempt  to  save  the  limb;  or  docs  its 
condition,  with  the  want  of  proper  facilities  for 
ii>  successful  treatment,  necessitate  its  condem- 
nation? If  we  have  had  experience  in  the  eare 
of  guushol  fractures,  we  should,  with  Sir  Charles 
Bell,  contemplate  what  will  be  the  condition  of 
the  parts  in  twelve  hours,  in  six  days,  or  in 
three  months.  "In  twelve  hours  the  inflamma- 
tion, pain  and  tension  of  the  whole  limb,  the 
inflamed  countenance,  the  brilliant  eye,  the  sleep- 
i<  9e  and  restless  condition,  declare  the  Lnipres- 
lioB  the  injury  is  making  on  the  limb  and  on 
tic  constitutional  powers.    In  six  days,  the  limb, 

from    tic   groin    to   the  toe,    or    from    the   shoulder 


* 


N!  POUND  FRACTURE  <>F  TnE  EXTRKMITII  H 

to   I  ivolleii  to   half   the  siae  oi    I 

body;  a   violent    phlegmonous  inflammation   per- 
vades the  whole;  serous  effusion  baa  taken  pli 
in  the  whole   limb,  and  al  are  forming  in 

the  greal  beds  of  cellular  texture  throughout 
the  whole  extent  of  the  extremity.  In  three 
months,   if  the  patienl   hae  labored   through  the 

my,  tin'  bones  are  carious;  the  abscesses  ate 
interminable  Bin  uses;  the  limb  is  undermined 
and  everywhere  unsound,  and  the  constitutional 
strength  ebbs  to  the  lowest  degree."  All  these 
conditions  must  be  rapidly  considered,  and  with 
tin  in  the  move  immediate  dangers  of  mortifi- 
cation, and  the  remote  dangers  of  erysipelas, 
pyaemia  and  hectic,  and  the  questionable  utility 
of  the  limb,  when,  after  Beveral  months  oi  con- 
tinued   trials,    the   wound   has   been    healed. 

Business  presses  and  time  is  valuable.  Within 
twenty-four    hours,   or    before    reaction    sets    in, 

whilst    the    patient    has    his    sensibilities    depressed 

\>\  the  shock,  our  conclusions  musl  be  made  and 
acted  upon;  success  of  treatmenl  depends  upon 
prompt  action — the  delay  of  a  few  days  lias  de- 
stroyed thousands  of  wounded.  Should  amputa- 
tion be  required,  there  is  no  period  in  the  progn 
oi'  the  case  so  favorable  for  the  performance  of 
this  operation  as  the  first  four  and  twenty  hours. 


COMPOUND  FRACTURE  OF  THE  EXTREMITIES.        ol)9 

Should  ;in  injudicious  attempt  be  made  to  save 
the  Limb,  amputation  cannot  be  resorted  to  with 
any  hope  of  success  until  suppurative  action  has 
hem  well  established.  Should  erysipelas  attack 
tlic  wound,  an  amputation  is  impracticable  ;  and 
whan  gangrene  lias  supervened,  during  the  stage 
of  reactionary  excitement,  we  are  driven  to  an 
operation  under  the  most  unfavorable  circum- 
stances. 

There  are  numerous  compound  fractures  upon 
which  judgment  can  he  immediately  passed:  with 
some,  there  is  every  probability  that  the  limb  ean 
be  saved;  whilst  there  are  others  in  which  the 
limh  is  condemned  at  a  glance  —  our  prognosis 
being  based  upon  the  following  circumstances: 
A.s  the  Upper  extremity  ean  sustain  a  much 
more  serious  injury  than  the  lower,  we  may  lay 
it  down  as  a  rule  that  a  compound  fracture  of 
any  of  the  Long  hones  of  the  arm,  when  not 
complicated  with  excessive  crushing  of  the  soft 
parts,  or  injury  to  hlood-vessels  and  nerves,  ean 
and  should  be  saved.  An  arm  is  rarely  to  he 
amputated  except  from  the  effects  of  a  cannon 
shot,  which,  besides  crushing  the  hones,  makes 
Erightful  Lacerations  of  the  mi\  tissues,  tearing 
away  muscles,  nerves,  and  blood-vessels,  and  of- 
ten amputating  completely  the  limh,  the  surgeon 


* 


370  TREATMENT    OF    0OMPO1  M>    VK.V   I  !  i:  !  - 

being  required  only  t<>  give  a  better  form  to  the 
stamp. 

For  a  gunshot  wound  from  a  musket  or  Minnie 
ball,  which  has  fractured  the  bones  of  the  arm 
without  implicating  a  joint,  the  following  is  the 
course  t<>  In-  pursued  :  At  tin'  field  infirmary  the 
wound  is  carefully  probed  with  the  linger,  ami  its 
spiculated  condition  noted.  All  Loose  fragments 
are  to  he  removed  at  this  first  examination  before 
reaction  ensues,  I'm-  it  will  be  very  injurious  to  the 
wound,  as  well  as  excessively  painful  to  the  boI- 
dier,  to  continue  Buch  examinations  from  day  to 
day.  The  first  examination  should  always  he 
effectual.  The  patient  is  then  Buffering  from 
shock,  with  sensibility  temporarily  blunted,  and 
is,  therefore,  in  the  besl  condition  to  he  operated 
upon.  To  render  this  first  examination  complete, 
should  the   shock    have  passed   off  and  the  patient 

complain  of  much  pain,  it  would  be  better  to  give 
him  large  doses  of  opium,  or  administer  chloro- 
form, rather  than  desist  from  this  important  por- 
tion of  tlie  treatment.  Should  we  omit  to  bring 
away  all  spiciihe.  the  further  removal  should  not 
he  attempted  during  the  Btage  of  excitement  and 
febrile  reaction  which  will  come  on  after  twenty- 
lour  hours,  and  which  wili  run  its  course  in  six 
or  eight  days.       When   this  sulfides,  then  and  not 


and  no 


TREATMENT  OF  COMPOUND  FRACTURES.     371 

before,  we  make  the  second  examination,  and  by 
the  use  of  instruments,  remove  any  loose  frag- 
ments which  wo  now  detect.  We  will  simply 
mention,  in  this  connection,  that  as  there  is  not 
the  slightest  probability,  or  even  possibility,  of 
the  wound  closing  by  the  first  intention,  the  in- 
sertion of  tents  and  pieces  of  lint  is  a  relic  of 
barbarous  surgery,  which  being  useless,  injuri- 
ous, and  very  painful,  cannot  be  too  severely  con- 
demned. 

Modern  surgery  recommends  that  all  spicuho, 
whether  detached  or  not.  should  be  removed:  hut 
this  practice  is  not  upheld  by  surgeons  generally. 
Experience  and  observation  has  in  some  instances 
shown,  that  although  the  larger  fragments  may 
he  detached  from  the  shaft  of  the  hone,  they 
may  siill  he  adherent  to  the  periosteum,  which 
will  effect  a  reunion  and  consolidation.  On  the 
other  hand,  experience  and  observation  have 
shown  that,  from  the  force  with  which  conical 
shot   Strike   a   hone,    the   spicuho,    which    are    very 

numerous,  are  driven  in  every  direction,  hut  gen- 
erally toward  the  opening  of  escape  of  the  ball. 
These  Bharp  splinters  canuol  but  produce  ex- 
e  irritation  in  the  soft  parts,  and  may. 
by  transfixing  vessels,  pricking  nerves,  or  irritat- 
ing muscles,  induce  hemorrhage,  mortification,  or 


«i 


SJ72  IIU.ATMKNT    OS    OOMPOUMD     lltAlTI   l!l- 

lotaiiuo.      N<  •  •  'ii  doubts  the  prop 

moving  all   such   on    the   Bpot,   or  :it    tin-  earliest 
p<  -iMr  moment.     A.>  the  opening:  of  exit,  around 
which  iIm-  larger   Dumber   of  the    fragments   mv 
fouud,  may  be  toe  oontraeted  to  admit  of  a  ihor- 
ongh   exploration  of  the  wound,   it   will   not   in- 
creaae  the  dangers  but,  on  the  contrary,  materially 
diminish  the  risks  of  after-trouble,  it   the  wound 
of  exit,  in  compound  fractures  with  crushing  of 
the  bone,  be  dilated,  bo  as  to  facilitate  the  oLsti 
tiuii  and  removal  of  every  spicula.     In  enlarging 
this  orifice,  injury  to  the  important  blood' 
ami  nerves  will,  of  course,  be  avoided. 

On  the  subject  of  removing  oil  fragments, 
whether  detached  or  not.  there  appears  to  be  I 
diversity  of  opinion,  which  is  based  upon  the 
changes  introduced  into  modern  warfare.  Tbe 
older  surgeons,  who  base  their  treatmeul  on  the 
effects  of  musket  halls,  know  that  often  the  ass* 
paction  of  tin-  fragments  to  hhe  Bofl  parte  and  bo 
tlir  periosteum  will  guarantee  a  consolidation  of 
the  fragments.  The  round  bail  simplj  breaks 
tin'  bone  without  scattering  the  fragments,  and. 
therefore,  their  relations  to  the  surrounding  tis- 
Baee  will  not  be  so  materially  changed.  Bnt, 
notwithstanding  this  impression,  which  may  or 
may  not   be  correct,  what  does  actual  experience 


TREATMENT    OF    COMPOUND    FRACTURES.  373 

prove,  when  brought  down  to  tacts?  Take  the 
experience  given  by  the  inmates  of  the  Hotel  dee 
Invalides.  as  recorded  by  M.  llutin.  the  surgeon 
of  the  institution.  He  states,  that  those  spicules 
which  had  been  attached  to  the  soft  parts,  and 
which  Mere  allowed  to  remain  in  the  hope  of 
reunion,  although  they  may  not  give  trouble  at 
the  moment,  invariably  end  by  becoming  seques- 
tra, and.  after  a  long  period  of  pain  and  sup- 
puration, demand  removal.  He  reports  several 
hundred  cases  in  which  the  retained  fragments, 
sooner  or  later,  set  up  an  eliminative  action, 
which  is  always  painful,  often  dangerous,  and  at 
times  fatal.  M.  Hutin  refers  chiefly  to  the  effects 
of  round  or  musket  halls.  Baudens  gives,  as  his 
Crimean  experience,  "that  whether  adherent  or 
not,  it  is  better  to  remove  all  spienhe.  and  thus 
simplify  the  wound.  If  these  be  retained,  end- 
suppuration,  continued  Buffering,  with  exac- 
erbations of  all  the  svmptoms  at  the  escape  of 
each  fragment,  will  gradually  exhaust  the  vital 
forces,  and  entail  it-  seqttelss  of  marasmus,  diar- 
rheea  and  hectic."  Suppuration  will  eventually 
bring  all  of  the  fragments  to  the  surface,  but  at 
what  a  sacrifice! 

McLeod,  after  quoting  the  experience  of  Roux, 
l»aiid<n-.    Guthrie,    llutin.    Dupuytren.    Ourliivj*, 


:;7  I  TREATMENT    OF    COMPOUND    FRACTL1 

Begin,  and  others,  on  the  dangers  of  allowing 
movable  fragments  to  remain,  and  the  necessity 
of  extracting  every  piece  which  i-  nol  extensively 
attached  to  the  Bofil  parts,  gives  his  experience 
a-  decidedly  in  favor  of  the  modern  practi< 
removing  all  movabU  spieula  as  the  best  mod 
basteniug  a  tin.'  and  diminishing  mortality,  "as 
the  removal  must  tend  immensely  t<>  simplify  the 
wound." 

Again,  he  says:  "Tin'  extensive  comminution 
of  tin-  bone  by  a  conical  bail,  makes  the  indi- 
cation.- with  regard  to  tin'  management  of  the 
sequestra  more  evident  than  it  i>  commonly  <-on- 
sidered.  1  do  oot  think  that  we  paid  sufficient 
attention  to  their  removal  in  the  Bast  It  may 
he  true  as  some  tell  as,  that  in  fractures  with 
the  old  hall,  it  was  desirable  t«>  meddle  as  link- 
as  possible  with  the  fragments;  hut  this  i>  the 
teaching  of  only  a  few.  However,  to  my  mind, 
the  question  ;is>mncs  a  totally  different  light 
when  viewed  by  the  pathological  results  which 
we  bad  occasion  to  witness." 

Borne  surgeons  go  further,  and  recommeud  that 
not  oniv  should  all  spicule  he  removed,  but  that 
tin'  sharp,  irregular  ends  of  the  bones  should  be 
sawed  oil'.  This  suggestion  lias  not  met  with 
general  approval,  and  is  spoken  of  by  Stromyer 


TREATMENT    OF    COMPOUND    FRACTURES.  375 

and  LoefBer  as  no  improvement.  Their  experi- 
ence  gave  a  larger  mortuary  list  when  this  prac- 
tice w:is  attempted. 

There  is  no  doubt  that  the  removal  of  all  frag- 
nu'iiis.  in  which  there  is  not  a  strong  probability 
ci'  reunion  taking  place,  will  expedite  the  cine. 
In  surgery,  whenever  we  are  in  doubt,  we  should 
always  give  the  patient  the  benefit  of  it;  and  in 
the  subject  under  consideration,  knowing  that 
the  removal  of  s]>ieul;e.  which  niiuhl  eventually 
become  consolidated,  can  do  no  harm,  whilst  leav- 
ing theni  in.  should  union  not  be  obtained,  would 
be  followed  by  much  danger,  annoyance  and  Buf- 
fering, we  give  the  patient  the  benefit  of  the 
doubt,  and  remove  them  at  the  first  examination. 
Feeling  now  secure  that  we  have  removed  every 
foreign  body,  and  have  left  nothing  in  the  wound 
which  is  likely  to  retard  the  cure,  we  should 
ignore  the  presence  of  the  wound  as  much  as  pos- 
sible, and  treat  ihe  case  as  one  of  simple  fraetuiv. 
Inflammation  and  suppuration  we  expect  ;  they 
generally  accompany  compound  fractures,  and  es- 
pecially those  connected  with  gunshot  wounds: 
and  remembering  the  long  continued  ami  profuse 
drain  which  will  establish  itself  in  four  or  live 
days,  we  should  be  careful  how  we  make  use 
of  active  antiphlogistic   treatment.      For   the   first 


376  TKKATMKNT    OF    OOMPOl  \'l»    FRACTURES. 

week  or  tin  davs.  the  arm  may  be  stretched 
upon  a  pillow,  or  loosely  secured  to  a  broad, 
long  splint,  which  will  support  the  entire  ex- 
tremity. We  confine  the  treatment  to  cold  water 
dressings,  either  l>v  iced  bladders,  applied  over 
compresses  to  remove  the  injurious  effects  of  di- 
rect application*  or  by  the  process  of  irrigation — 
either  of  which  is  better  than  the  continued 
renewal  ot'  wet  cloths.  The  general  treatment, 
during  this  period  of  inflammatory  excitement, 
is  diet,  rest,  quiet,  and  the  use  of  mild  diapho- 
retics,  diuretics,   and  the  liberal   use  of  opium. 

Tain  we  do  not  consider,  in  any  sense,  n< 
sary  to  the  healing  of  wounds,  and.  therefore. 
have  always  made  it  a  rule  in  practice  to  reduce 
it  t<>  its  minimum.  The  complete  annihilation 
of  pain  will  neither  detract  from  the  rapidity  of 
healing,  nor  from  the  gratitude  (A'  patients.  Tim 
impropriety  of  free  catharsis,  will  he  at  once  evi- 
dent from  the  movements  made  necessary  by 
their  action.  Bloodletting,  emetics,  and  the  use 
of  mercury  we  absolutely  discard,  as  always  use- 
less  and    injurious   in    the   treatment    of   any   stage 

of  compound  fracture-.  As  Boon  as  the  period 
of  inflammatory  reaction    has   subsided,  we  then 

apply    such     splints     to     the    arm     as    will     secure 

quiet  and   rest   to  the  liml».  whilst  a  \v<-r  vent   i> 


COMPOUND    FRACTURES    OF    THE    ARM.  o77 

allowed  in  the  apparatus  for  the  escape  of  &W 
charges  from  the  wound — this  opening  also  per- 
mits water  dressings  being  applied  to  the  wound. 

Tt  cannot  be  expected  that  an  arm.  after  a 
serious  gunshot  injury  to  the  bones,  will  lie 
cured  without  deformity.  The  arm  will  always 
be  shortened,  wliere  many  spieuhe  have  been  re- 
moved. We  acknowledge  this  feet  in  anticipa- 
tion, and  never  attempt,  by  traction  and  coun- 
ter-extension, to  restore  it  to  its  former  length; 
We  simply  place  the  arm  in  an  easy  position 
and  allow  the  muscles  to  approach  the  broken 
ends.  In  the  treatment  of  simple  fractures, 
the  main  object  is  to  prevent  deformity,  and, 
especially,  shortening  of  the  limb.  As  this  ob- 
jert  is  discarded  in  compound  fractures  of  the 
upper  extremity,  the  treatment  becomes  much 
simplified,  and  the  patient  is  saved  its  greatest 
annoyance. 

In  fractures  of  the  arm.  the  pasteboard  spliiirs 
are  to  be  preferred;  whilst  for  the  forearm, 
wooden  splints,  made  of  light  material  and  wider 
than  the  diameter  of  the  arm,  will  make  the 
best  application.  The  tumefaction  bandage  is 
not  now  insisted  on,  and  by  many  Burgeons  is 
altogether  discarded.     In  gunshot  injuries,  where 

we     have     an     open    wound     to    dress     daily,    our 


378  MI'<>1    Mi     11!  \<    II   UB    n(     THK    ARM. 

mechanical  applications  should  be  of  such  a 
character  at  to  permit  o£  easy  inspection,  and 
also  the  ready  readjustment  of  the  apparatus 
when  disarranged,  whilst,  at  the  same  time,  the 
splints  are  kepi  secure.  Diachjlon  plaster  is 
now  extensively  used  to  secure  splints  t<>  frac- 
tured limbs;  1 1 1 r* ■» •  or  four  bands  encircling  the 
limb  will  always  secure  the  supporting  appa- 
ratus, while!  the  limb  remains  open  to  inspect 
tion.  When  the  pasteboard  is  moistened,  it 
moulds  itself  to  the  arm  and  makes  a  very  sat- 
isfactory dressing. 

A-  soou  as  the  patient  has  passed  the  roae 
tive  stage,  he  should  no  Longer  be  confined  t<» 
his  bed,  1'iit  with  his  arm  in  a  sling  may  obtain 
sufficient  exercise  to  keep  his  Bystem  in  good 
order.  The  erect  position  will  have  the  addi- 
tional advantage  of  permitting  the  ready  dis- 
charge of  i»us.  and  will  prevenl  the  bagging  of 
this  liui  I,  and  obviate  the  necessity  for  tin-  estab- 
lishment <»f  counter-openings.  In  all  Bimple  fraa- 
tures,  tin'  excess  of  callus  depends  upon  the  de- 
gree "i'  mobility  between  the  broken  ends.  In 
compound  fractures  the  deposil  for  consolidation 
i-  usually  very  great,  which  may  he  explained 
by  tie  amount  of  irritation  from  inflammatory 
action,  ami  also  by  the  difficulty  of  keeping  the 


COMPOUND    FRACTURES    OF    THfl    ARM.  •  >,!• 

fragments  at  rest.  Fortunately,  this  docs  not 
interfere  with  the  final  results,  as  false  joints 
are  not  more  frequently  met  with  in  compound 
than  in  simple  fractures.  Experience  shows  us 
that  there  is  not  that  necessity,  which  many 
practice,  of  frequently  tightening  the  apparatus, 
to  the  very  great  annoyance  of  the  patient.  If 
the  constitution  he  strong,  a  considerable  degree 
of  relaxation  may  he  permitted,  and  he  found 
not  incompatible  with  perfect  consolidation.  In 
animals  with  compound  fractures,  we  sec  contin- 
ual exemplifications  of  this  fact;  their  broken 
hones  becoming  united,  notwithstanding  the  con- 
tinued motions  of  the  Limb,  in  the  absence  <>l" 
all   retentive  apparatus. 

The  local  and  general  treatment  of  the  wound 
will,  in  no  respect,  he  modified  on  account  of 
the  fracture.  Water  dressings,  until  cicatrization 
is  completed,  medicated  with  astringents  to  al- 
lay profuse  discharges,  or  with  antiseptics  to 
remove  fetor,  or  with  stimuli  to  promote  gran- 
ulations, will  be  the  proper  course,  whilst  the 
genera]  health  is  watched,  retarded  secretions 
promoted,  and  debility  guarded  against.  If  frag- 
ments of  hone  have  remained  and  have  become 
necrosed,  the  Burgeon  must  assist  nature  in  the 
expulsion  ;i>  soon  as  they  have  become  detached, 


MPOUNTl     FH  \<TI  111'-    OF    TR  I      \I(M 

otherwise  they  will  be  Bttrrouuded  by  new  for- 
mations, and,  as  sequestra,  incarcerated  in  an 
involacrura,  will  only  be  expelled  after  much 
time  and  trouble.  When  Bpfculte  are  Buspected, 
the  wound  should  be  examined  from  time  to 
time,  and  especially  aboul  the  eighth  or  tenth 
•  lav  from  the  receipt  <>t'  injury,  when  the  swell- 
ing has  Bubsided  to  such  an  extent  that  the 
finger  can  be  introduced.  From  the  passing  off 
of  tlic  shock  until  the  period  of  reaction  has 
subsided,  all  examination  of  the  wound  must  be 
absolutely  interdicted.  During  the  first  week,  no 
one  should  be  permitted  to  probe  the  wound. 
A.a  -"Mil  as  we  conclude  that  all  fragments  have 
been  removed,  we  desisl  from  all  further  prob- 
ing, as  it  cannot  hut  be  injurious  to  the  deli- 
cate granulations. 

Cleanliness  is  necessary  to  successful  hospital 
practice  in  the  treatment  of  suppurating  wounds, 
btft,  when  excessive,  becomes  a  Berioua  obstacle 
to  rapid  cicatrization.  It  is  a  common  error  for 
surgeons  to  place  a  wounded  limb  over  a  basin 
<>f  water,  and  sponge  and  nil»  it  at  it  they  were 
cleansing  a  piece  of  porcelain  I  have  -ei-n 
others  cleanse  gunshol  wounds  by  the  free  use 
of  a  powerful  syringe,  with  which  they  poured  a 
stream  of  water  into  the  wound   until  the  granu- 


I'oMI'iU'XIi    FRACTURES    or    THK    ARM.  -5s  I 

lntions  were  bleached  and  the  water  returned  dis- 
colored with  blood,  and  this  repeated  with  greal 
regularity  at  the  morning  and  evening  visit.  Tt 
was  not  surprising'  that  wounds,  treated  with  this 

over-care,  took   a   very   long  time  to   heal. 

This  too  liberal  use  of  the  syringe  is  a  very 
common  error  with  sum-eons,  who  overlook  the 
protective  influence  of  healthy  pus  in  their  over- 
estimate of  excessive  cleanliness.  I  have  seen  a 
surgeon,  in  a  ease  of  resection  of  the  shoulder 
joint,  which  promised  a  speedy  and  successful 
cure,  put  the  heak  of  a  syringe  into  one  of  two 
or  three  fistulous  tracks  through  which  the  liga- 
tures had  escaped,  and  distend  the  cavity  until 
jets  d'eau  spouted  from  the  opposite  orifices,  the 
perspiration  streaming  from  the  face  of  tin1  pa- 
tient, and  the  distorted  countenance  indicating 
the  unnecessary  torture  which  tic  surgeon  was 
inflicting.  AVas  it  singular  that  the  ease  retro- 
graded from  the  time  this  rude  and  ignorant 
practice  was  instituted  ?  and  could  any  other 
reeuh  have  been  reasonably  expected  ? 

if  the  wound  he  gangrenous,  and  the  object 
In-  to  remove  ichorous  decomposing  fluids,  to  di- 
minish or  prevent  absorption  and  general  poison- 
ing, then  the  syringing  i-  desirable  ;  hut  tinder 
no  other  conditions  should   the  granulating  sur- 


388  Ml'i.l  ND    FRAC1  I   HKS    01    TIIK    ARM. 

face  of  a  wmiiimI  be  washed.  Wipe  around  the 
edges  :ui«l  remove  any  secretions  which  might 
have  eolleeted  upon  the  akin,  but  leave  the  put, 
as  the  best  eovering  which  healthy  granulations 
can  have.  Under  its  protection,  the  plasma, 
which  is  thrown  out  from  the  blood-vessels,  will 
rapidly  form  tissues;  but  rub  < »r  wash  away  this 
covering,  and  the  exposure  to  the  baneful  influ- 
ences of  the  atmosphere  will  rapidly  destroy  the 
granulations  which  had  already  formed.  How- 
ever useful  the  local  and  general  bath  is  to  ad- 
vance the  cicatrization  of  a  suppurating  wound, 
do  not  generalize  too  much,  and  expect  equally 
good  service  from  cleansing  the  granulations. 

Compound  fractures,  under  the  \ « •  i  \  besl  condi- 
tions, arc  tedious  oases,  and  in  gunshot  injuries 
our  patience  will  often  be  taxed  to  bhe  utmost 
Despondency  should  not  be  an  element  in  thi 
character  of  a  military  surgeon.  We  niusl  ex- 
pect to  have  a  compound  fracture  under  treat- 
ment at  least  twice,  if  not  three  times  as  long 
as  would  be  required  to  consolidate  a  simple 
fracture. 

Bhould  the  main  vessel  be  injured,  in  connec- 
tion with  the  fractured  bones,  we  have  not  suffi- 
cient cause  to  sacrifice  the  limb;  but,  ligating 
the  arten   at    "s  bleeding  mouths,  we  treat   the 


TREATMENT  OF  GUNSHOT  INJURY  OF  JOINTS.        383 

fracture  as  if  this  complication  had  not  existed. 
Owing  to  the  free  anastomosis  of  the  blood-ves* 
sels  of  the  arm,  mortification  is  not  to  be  Seared 
when  a  ligation  is  applied  even  to  the  brachial 
artery;  a  circuitous  route  soon  supplies  the  need- 
ful nourishment  to  the  parts  beyond.  Should 
the  nerves  as  well  as  the  artery  be  injured,  or 
the  principal  nerves  alone  with  the  bones,  then 
the  limit,  even  when  saved,  Mould  be  a  useless. 
paralyzed  extremity,  and  its  immediate  removal 
will  save  the  patient  a  long,  tedious,  and  danger- 
ous convalescence.  In  such  eases,  it  is  our  duty 
to  sacrifice  the  limb  to  diminish  the  risks  to 
life. 

The  most  dangerous  fractures  of  the  extremi- 
ties are  those  involving  the  heads  of  the  bones 
and  extending  into  a  joint.  The  synovial  injury 
add-  greatly  to  the  danger  of  the  case,  ami  in 
former  times  was  considered  nearly  a  fetal  com- 
plication, as  it  necessitated  an  amputation,  which, 
under  the  ordinary  circumstances  attending  hos- 
pital treatment,  was  not  far  removed  from  a  fatal 
termination.  Nor  have  we  now  much  to  hoast 
<>f:  for,  when  amputations  near  the  trunk  are 
required,  notwithstanding  all  the  improvements 
in  modern  seieii<-<>.  we  succeed  but  little  better 
in  checking  the   fearful   mortality. 


*J£4        TRKATM1  NT  "1    Ol   N8HOT   1N.il  l!V  OF  Joints. 

The  -'•v.tiiv  of  the  Bvmptoms  of  articular  in- 
juries depend  upon  the  size  of  the  joint  mid 
the  character  of  the  wound.  The  dangers  mv 
serious  enough  with  1 1  u  ■  smallest  puncture,  but 
when  the  wound  is  large  and  lacerated,  exten- 
biyc  local  mischief  and  constitutional  disturhance 
i>  Bure  to  ensue,  leading  with  certainty  to  the 
destruction  of  the  joint,  and  usually  destroying 
the  patient.  Hence-,  in  the  days  of  John  Bell, 
the  united  experience  of  surgeons  considered 
wounds  of  joints  mortal.  Crimean  experience 
corroborates  John  Bell's  conclusions,  as  no  seri- 
ous injury  to  the  large  joints  recovered  unless 
the  limbs  were  amputated  ar  joints  resected.  TW 
great  fear  is  not  in  the  serious  injuries,  as  these 
cases  are  at  ontje  operated  upon.  It  is  in  the  ap- 
parently trivial  ease,  where,  from  the  very  small 
size  of  the  wound,  we  hope  that  no  trouble 
will    supervene,   tliat   violent    inflammation     shows 

itself  and   life  is  sacrificed. 

A  wounded  joint,  under  the  ordinary  hospital 
treatment,  will  exhibit  the  following  Bymptoms: 
When  a  hall  has  perforated  the  joint,  the  pe- 
riod of  reaction  is  not  long  absent.  In  exten- 
<ive  wounds  a  great  degree  of  nervous  shock 
accompanies  the  injury,  the  patient  lying  deadly 
pale,   eold   and   faint.      In   from   twelve   to  twenty- 


TREATMENT  OF  GUNSHOT  INJURY  OF  JOINTS.        385 

lour  hours,  the  tissues  around  the  articulation 
become  hot,  swollen,  and  painful;  inflammation 
has  already  seized  upon  the  synovial  membrane, 
and  will  soon  involve  all  the  structures.  All 
the  symptoms  rapidly  increase  until  they  heconie 
excessive.  There  is  no  rest  for  the  weary  suf- 
ferer, who,  in  spite  of  iced  applications,  and  the 
free  use  of  morphine,  with  the  entire  arcana  of 
antiphlogistic  remedies,  writhes  about  in  unmiti- 
gated agony.  If  the  aperture  leading-  into  the 
joint  be  made  by  a  ball  or  piece  of  shell,  the 
synovia  at  first,  and  in  two  or  three  days  pus, 
freely  escapes.  Should  the  entrance  into  the 
joint  be  small  or  the  passage  oblique,  the  puru- 
lent synovia  tills  and  distends  the  joint,  adding 
much  to  the  pain  which  is  increased  by  the 
irregular  spasmodic  contractions  of  the  surround- 
ing muscles. 

Accompanying  these  local  symptoms  will  be 
found  a  high  grade  of  inflammatory  i'vwv,  with 
rigors,  great  gastric  distress,  intense  thirst,  ex- 
cessive restlessness,  and  with  such  an  amount 
of  constitutional  disturbance  as  sometimes  to 
destroy  life  in  a  few  days.  As  the  disease  ad- 
vances, abscesses  form  in  the  surrounding  tis- 
sues by  extension  of  the  inflammatory  process, 
and   in   a   few  days,  open   continuous   passages  to 


3sf>     TitKATMiN:  "i  0CN8H0T  injoth  op  jon 

the  joint,  from  which  a  constant  discharge  of 
purulent    matter   escapi 

[f  the  patieni  is  no1  destroyed  in  the  early 
-  of  the  disease  by  erysipelas,  pytemia, 
etc.,  in  connection  with  the  irritative  fever,  he 
tails  a  prtey  to  hectic,  caused  by  the  continued 
drain  from  the  disorganized  joint:  synovial  mem* 
brane,  cartilages,  and  bones  forming  one  mass 
of  disease.  In  gunshot  wounds  of  joints,  very 
rarely  does  tin-  patient  escape  with  life  in  mili- 
tary hospitals.  In  private  practice  he  some- 
Times  recovers,  bu1  even  under  the  most  advan- 
tageous circumstances  a  successful  case  is  rarely 
seen,  and  then  usually  with  a  destroyed  and  an- 
chvlosed  joint.  As  the  results  in  injured  joints 
are  so  fatal,  surgeons  had,  ai  an  early  day, 
adopted  amputations  as  giving  the  only  chance 
for  recovery.  In  recent  years,  conservative  sur- 
srerv  lias  introduced  the  operation  of  resection 
as  affording  no1  only  the  means  of  preserving 
life,    but   also   of   saving   a    useful    limb. 

The  diagnosis  of  articular  injury  is  usually 
evident  from  the  direction  of  the  wound,  and 
from   the  escape  of  synovia:  at  times,  however, 

when    the    orifice    is   small   and    the    wound   ciivui- 

bous,  ;i  successful  diagnosis  requires  much  expe- 
rience  and  close  observation.      When  possible,  a 


RESECTIONS  PREFERABLE  TO  AMPUTATIONS.        387 

consultation  should  always  be  had  over  these 
cases'.  It  is  in  these  very  cases  of  doubt,  or  erf 
apparently  trivial  injury,  that  the  most  violent 
reactionary  Bymptoms  are  met.  and  that  a  fatal 
issue  occurs.  If  left  unoperated  upon,  the  tri- 
fling wound,  perforating  the  joint,  might  nearly 
be  considered  mortal ;  whilst,  if  the  joint  be  not 
implicated,  the  operation  of  resection  is  not  only 
not  called  for,  hut  unnecessarily  risks  the  lite 
of  the  individual.  The  urgent  necessity  for  ah 
accurate  diagnosis  is  evident. 

For  injury  to  joints  in  the  upper  extremity 
resection  is  particularly  applicable,  and  this  op- 
eration is  now  the  rule  of  practice,  having  su- 
perseded amputation  in  all  eases  where  the 
blood-vessels  and  nerves  around  the  joint  are 
not  involved  in  the  injury.  When  a  joint  has 
in  any  way  been  injured  by  a  gun-shot  wound. 
whether  the  articulation  has  only  been  opened, 
or  the  heads   of  the   hones  forming   it   crushed, 

a-  BOOB  as  the  excessive  shock  under  which 
the  patient  may  he;  suffering  passes  oil",  we 
proceed  at  once  to  operate.  A  primary  re- 
section is  as  essential  as  a  primary  amputation, 
and  is  followed  by  as  successful  results.  It 
should  he  performed  within  twenty-four  or 
thirty-six  hours,  or  before  reaction  sets  in.    Such 


IONS   J'UKKI  KAlll.l.    In   A'.,IM    CATIONS. 

cases  would  do  much  better  if  the  patient  could 
be  transferred  to  the  genera]  hospital  prior  to  an 
operation,  as  transportation  is  difficult  and  dan- 
gerous immediately  after  the  resection,  from  the 
difficulty  of  securing  the  limb  from  movements. 
Should  the  case  not  come  under  observation  un- 
til reaction  lias  come  on,  then,  by  general,  mild, 
antiphlogistic  treatment,  and  ice  Madders  or  cold 
water  dressings  locally,  we  awarl  the  establish- 
ment of  suppuration,  when  the  operation  might 
be  attempted  with  good  prospects  of  success. 

The  results  of  the  primary  resection  are  more 
successful  than  the  seoondary;  and  these  arc  in 
turn,   much   more   likely    to   succeed    than    when 
the  operation   is   performed  during  the   stag 
febrile  excitemeot. 

There  arc  three  or  four  rules  necessary  in  all 
cases  of  resection,  and  which  should  not  be 
forgotten  during  the  operation,  viz:  Make  the 
incisions  for  exposing  the  heads  of  the  bones 
in  that  portion  of  the  extremity  opposite  to  the 
main  Mood-vessels  and  nerves,  so  that  these 
may  no1  he  exposed  to  injury.  If  possible, 
make  the  existing  wound  lie  in  the  line  of 
one  of  the  incisions,  and  place  the  incisions  in 
such  a  way  as  to  permit  a  continued  drain  from 
the  joint.      Make    these    iuci.-dons    free,    so    as    not 


RESECTION    OP    THE    STTOT'LOER-.TOTXT  8SD 

to  cramp    the  operator  in    turning   oilt  the  heads 

of  the  bones.  An  ineli  added  to  the  incision 
does  not  increase  its  serious  character,  and  hast- 
ens the  operation.  Remove  most  of  the  synovial 
membrane,  and  save  as  much  periosteum  as  pos- 
sible: the  one  is  prone  to  take  on  inflammation, 
the  other  makes,  and  Will,  to  a  certain  extent, 
reproduce  the  bone.  In  performing  secondary 
resections,  the  removal  of  all  the  diseased  syno- 
vial membrane  becomes  one  of  the  first  elements 
for  success. 

More  successes  are  obtained  from  resections 
of  the  shoulder-joint  than  from  any  other  artic- 
ulation—  the  statistical  tables  of  the  final  re- 
sults oi'  operations  in  favor  of  resection  being 
conclusive  over  amputations.  The  following  is 
the  course  recommended  for  performing  the  op- 
eration of  resection,  a  substitute  for  amputa- 
tion of  the  arm:  a  I"  shaped  flap,  about  three 
inches  in  length,  is  made  of  the  deltoid  mus- 
cle, on  the  upper  and  outer  portion  of  the 
arm  :  if  there  be  any  wound  on  this  portion 
ot*  the  extremity,  make  one  branch  of  the  in- 
cision include  the  wound.  The  knife  passing 
directly  to  the  bom1,  from  the  clavicle  or  accro- 
mial  process  downward  for  three  inches,  makes 
B    large  flap  of  the  deltoid,  which   is  raised   by  :i 


[OR    Off  tiik.   siioi  I. in. is  .hunt. 

few  touches  of  the  knife.  The  circumflex  arte* 
are  divided  in  tliis  first  incision,  and  Bhould 
be  at  once  ligated,  otherwise,  aa  the?  are  of  con- 
f~ i ( 1 » ■  s : 1 1  > I « •  size,  tin-  patient  will  lose  mncfa  Mood, 
and  the  steps  of  the  operation  1"'  obscured.  Bj 
carrying  the  arm  over  the  chest,  the  capsule  oJ 
tin-  joint  La  exposed  and  divided  transversely, 
and  with  it  the  rotary  muscles  of  the  shoulder, 
when  the  head  A\ill  protrude  from  its  position. 
Tin-  Long  head  of  the  biceps  is  carefully  removed 
from  its  bicepital  groove  and  protected  from  in- 
jury.  The  In. no  are  now  examined;  a  knife 
blade,  or  spatula,  as  a  guard,  is  placed  behind 
the  bone  so  as  to  protect  the  soft  parte  and  ves- 
sels from  injury,  and  all  of  the  injured  portion  is 
removed  with  the  saw. 

When  the  hall  has  entered  directly  within  the 
joint,  only  the  surface  may  require  excision  ;  Inn 
should  the  head  of  the  hone  he  extensively 
speculated,  we  must  cut  hack  to  the  sound  hone, 
even  if  we  arc  compelled  to  remove  four  or 
live  inches  of  the  shaft  of  the  hone,  as  was  w»- 
cessfully  done  first  by  Stromyer  lor  a  gunshot 
injury:  should  the  glenoid  cavity  he  equally  in- 
jured, the  fractured  portion  would  he  removed. 
The  rule  is.  never  to  remove  more  of  the  hone 

than    is    absolutely    called     tor.    and    not     to    open 


RESECTION    OF    THE    SHOULDER-JOINT.  391 

the  medullary  cavity  if  it  can  in  any  way  be 
avoided. 

When  the  wound  has  been  cleansed  of  all 
foreign  bodies,  the  flap  is  replaced  and  secured 
with  one  <>r  two  points  oi  suture.  As  adhesion 
by  the  first  intention  is  not  usually  expected, 
and  gives  n<>  advantage  over  the  final  result  by 
granulation,  nice  adjustment  is  not  necessary. 
The  natient  is  then  put  to  bed,  and  cold  water 
dressings  applied.  Inflammation  at  first  runs 
high,  the  parts  around  the  joint  are  mueh  swol- 
len, and  a  collection  soon  forms  within  the  cav- 
ity from  which  the  bones  have  been  removed. 
The  escape  of  this  decomposed  blood  and  pus 
from  the  wound  gives  great  relief.  When  kept 
in  by  the  too  nice  adjustment  of  the  flap,  the 
collection  increases  the  swelling,  u'dema.  and 
pain  which  is  diffused  over  the  neighboring  parts, 
involving  the  chest  as  well  as  arm.  When  sup- 
puration becomes  established,  the  swelling  ami 
pain  subside,  granulations  spring  up,  and  event- 
ually   close    the    wound.      Iii    the    meantime,     the 

divided  muscles  have  formed  new  relations:  by 
means  of  the  lymphy  exudation,  they  become 
more  or  less  incorporated  with  the  surrounding 
tissues,  aud  by  taking  an  insertion  around  the 
cut    portion    of  the    bone,    form    in    time   a   closed 


.'I!' ■_'  [ON    OF    THE    SU01  I  D1  R-JOIN 

I    head   bo  the  bo  ometimea,  in 

a  measure,  formed;  in  other  cases,  the  end  of 
the  bone  becomes  attach.  <1  i<»  t In-  cavity  by 
fibrinous  bauds.  <  >f  the  eases  of  resection  of  the 
Bhoulder  performed  in  the  Crimea  bnl  few  died; 
ami  all  those  saved  regained  a  aseful  limb,  pos- 
sessing all  the  motions,  with  the  exception  af 
those  oi  tin-  deltoid,  which  muscle  is,  to  a  cer- 
tain extent,  paralyzed  from  the  division  of  its 
nerves,  whioh  cannot,  altogether,  be  avoided  in 
exposing  the  head  of  the  bone. 

A-  Buppu  ration  will  be  excessive,  and  often 
long-continued,  nourishment,  and  even  stimuli, 
may  be  demanded  during  the  treatment.  When 
abscesses  form  in  the  Burronnding  cellular  tissue 
they  should  be  opened.  It  i.-  a  matte]-  of  but 
little  importunes  in  what  position  the  limb  is 
placed,  and  how  it  is  secured,  provided  its  pot* 
tion  i-  comfortable  to  the  Bufferer.  The  uneaei* 
uese  and  irritation  which  the  splints  and  bandages 
give,  do  much  to  prevenl  Buceese.  It  matters 
little  what  length  of  limb  the  patient  has,  pro- 
vided his  life  be  saved,  and  the  convalesce  nee 
In'  speedy.  A  shortened  arm  does  nol  affeel  its 
usefulness,  and  a  slightly  changed  direction  can 
be  corrected  in  the  after-stages  of  the  treatment. 
The  most   effectual  management   is  tin-  simplest; 


RESECTION    OF    THE    ELBOW-JOINT.  '■W 

and  tedious  daily  dressings  are  to  be  discouraged. 
Straightening  the  limb  apon  the  bod,  a  pillow, 
or  8    long,    broad    splint,   without   bandaging,   is 

tbe  best  and  most  comfortable  dressing  for  any 
resection.  The  patient  is  kept  in  bed  until  tbe 
suppurative  stage  is  established,  when  he  will 
be  permitted  to  get  up.  His  arm  is  then  placed 
in  a  sling,  and  the  water  dressings  ate  continued 
until  a  complete  cure  is  effected.  When  the  parts 
are  nearly  cicatrized,  it  will  be  time  enough  to 
apply  the  tumefaction  bandage,  for  removing  the 
(edema  of  the  limb.  Anchylosis  rarefy  follows 
this  operation  in  the  shoulder-joint.  As  a  proof 
of  the  efficacy  of  resection,  Stromyer  excised 
nineteen  shoulder-joints,  with  a  loss  of  seven, 
chiefly  from  pysemia.  Of  eight  eases  in  which 
tin'  operation  was  required,  but,  from  some  miti- 
gating circumstances,  was  not  performed,  five 
died. 

Gunshot  wounds  in  the  neighborhood  of  the 
elbow-joint  are  much  more  readily  recognized, 
by  the  escape  of  the  synovia,  etc..  than  injuries 
of   the    shoulder.      Inflammatory    reaction    runs 

high,   as    in    all    cases   in    which    joints    have   been 

opened    by  a   ball.     Collections   soon    form,    and 

the  excessive  swelling  stretches  the  softeiud  cap- 
sule, which,  giving   way.  allows  k\'  the  burrowing 


Kl  SECTION   O]     i  in.    BLBOK  401 

of  pus  and  final  discharge  through  open  abso< 
Alter  running  ;i  t « ■< i i » n  1  r~.  painful,  and  dangerous 
course,   it'  the    patient    escapes    with   a   shatl 
constitution    aud    an    anchylosed    limb,    it 
much   as   he  can  expect. 

A  primary  resection  offers  a  diminution  of 
the  risks  to  life,  a  rapid  convalescence,  and  a 
movable  joint,  in  the  Schleswig-Holstein  army, 
of  fifty-four  amputations  of  the  arm  niueteeu 
died;  whilst  of  forty  resections  under  similar 
circumstances  only  six  died.  The  results  of  the 
operations  were  also  modified  by  the  period  at 
which  the  resection  was  performed.  Of  eleven 
excised  within  twenty-four  hours  before 
reaction  ensued,  bat  one  died:  of  tweuty  cases 
between  the  second  and  fourth  day,  or  during 
the  stage  of  irritation  <>r  excitement,  four  died; 
and  of  nine  oases  operated  upon  between  the 
eighth  and  thirty-seventh  day,  only  one  died  : 
an  exemplification  of  ;i  general  rule  laid  down 
in  the  commencement  of  this  chapter,  that  the 
wounded  hear  operations  before  the  stag* 
reaction,  or  after  the  establishment  of  suppu- 
ration, much  better  than  thej  do  whilst  suffer- 
ing under  high  inflammatory  excitement.  This 
shows  the  necessity  of  deferring  secondary  op- 
erations until  the  proper  time  has  arrived,  which 
experience  has  determined. 


RESECTION    OF    THE    ELBOW-.TOTNT.  895 

The  elbow-joiui,  for  gunshot  wounds,  transfix- 
ing its  capsule  and  fracturing  the  bones,  is  best 
resected  from  the  baek  of  the  joint,  the  patient 
lying  upon  hie  abdomen.  An  II.  L,  or  T  incis- 
ion, taking  in  the  breadth  of  the  articulation, 
when  sufficiently  long  (from  torn-  to  five  inches), 
will  expose  perfectly  the  heads  of  the  bones. 
There  are  no  important  vessels  on  this  poste- 
rior portion  of  the  arm,  and  only  one  nerve,  the 
ulna,  which  must  be  sought  on  the  inner  side 
and  avoided  in  the  incision,  or  paralysis  of  all 
the  muscles  supplied  by  it  will  follow  its  section. 
When  the  posterior  Ligaments  are  divided,  and 
the  joint  exposed,  only  remove  the  fractured  head 
and  all  foreign  bodies,  and  do  not  interfere  with 
that  bone  which  has  not  been  injured.  The  lips 
of  the  wound  arc  closed  by  sutures,  and  cold 
w;iicr  dressings  become  the  principal  treatment. 
The  limb  is  placed  upon  pillows,  and  no|  dis- 
turbed, if  possible,  until  suppuration  is  estab- 
lished.  When  the  sofl  parts  are  cicatrizing,  and 
healing  is  nearly  completed,  passive  motions  in 
the  joint  will  prevent  anchylosis,  and  a  tumefac- 
tion bandage  will  remove  the  oedema  of  the 
limb. 

[■stances  of  successful  resections  are  recorded 
for  injuries  at  the  wrist-joint,  where  the  Bpiculated 


5-500  TIIF.    ri'I'KH   KXTKKMTTY  HAltll.Y 

ends  of  both  radius  and  ulna  have  been  satisfac- 
torily removed;  also,  instances  in  which  either 
of  these  bones  have  been  removed  entire,  for 
chronic  ostitis  and  necrosis  brought  on  from  gun- 
slioi  injuries.  Bimilar  incisions  to  those  recom- 
mended for  the  resection  of  the  elbow-joint  will 
expose  the  heads  of  the  wrist  bones,  and  permit 
of  the  ready  removal  of  any  injured  portion.  In 
this  as  in  all  other  cases,  we  must  save  all  ten. Ions 
passing  over  a  joint  to  supply  distant  bonee; 
and  in  the  wrist  particularly,  many  of  the  muscles 
which  supply  the  fingers  can  be  drawn  <>ut  of 
the  way  and  thus  escape  section. 

However  frightful  an  injury  involves  the  hand, 
it  is  very  seldom  that  it  is  so  mangled  as  to  be 
beyond  the  pale  of  surgical  skill,  and  unless  it  is. 
literally  ground  up  it  should  not  be  amputated. 
In  certain  cases,  fingers  may  have  been  already 
torn  oiK  or  may  be  hanging  by  a  fragment  of 
skin,  when  they  should  be  removed;  but  for 
ordinary  gunshot  lacerations  of  the  hand,  ampu- 
tation of  the  < utile  hand  is  very  rarely  required. 

Different  hones  of  the   hand   and  wrist  arc  to  ho 

removed  when  irrevocably  injured,  with  or  with- 
out the  metacarpal  hones  of  the  fingers  or  the 
thumb.  Any  fingers  which  can  be  saved  will 
he  better  than  the  best  artificial  limb.     In  cases 


REQUIRES    TO    BE    AMPUTATED.  397 

of  lacerated  hands  in  military  surgery,  when  at- 
tempts are  made  to  save  the  limb  under  cold 
water  dressings,  the  inflammation  which  comes 
on  makes  a  shocking  limb  to  those  unaccustomed 
to  treat  lacerations  of  this  extremity;  but  at  the 
end  of  eight  or  ten  days,  when  suppuration  has 
been  well  established  and  granulations  are  form- 
ing, the  swelling  subsides,  the  torn  portions  are 
drawn  together,  cicatrization  advances  rapidly, 
and  often  but  little  deformity  remains;  at  least, 
the  patient  retains  a  useful  limb.  Some  surgeons 
lav  down  the  rule,  that  an  amputation  of  the 
hand  is  never  imperative,  however  frightful  the 
injurv  to  it  may  appear;  and  there  is  much  truth 
in   the  assertion. 

Lt  the  inferior  extremity f  we  find  the  treatment 
of  gunshot  injuries  somewhat  ditlercnt  from  those 
of  the  upper  limb,  on  account  of  the  minor  degree 
of  vascularity,  and  the  much  greater  tendency  to 
mortification,  so  that  the  rule  to  which  we  called 
attention,  of  amputations  being  rarely  required 
for  the  superior  extremity,  is  reversed  for  the  Leg, 
where  it  te  often  the  only  way  of  escape  left  to 
save   the   life  of  the  wounded. 

We  have  elsewhere  slated  that  when  balls  em- 
bedded themselves  in  the  pelvic  bones,  and  their 
position  could  be  discovered,   provided  a   serious 


398  COMPOUND    FRACTURES    of   THE 

operation  is  not  needed.  tli«\  should  be  removed, 
;ts  their  presence  will.  Booner  or  later,  give  rise 
to  trouble.  All  loose  spicules  should  also  he 
taken  away,  and  as  Bequestra  frequently  Bhow 
themselves  from  time  to  time  during  the  treat- 
ment, they  should  l>e  withdrawn. 

Wlien  the  ball  strikes  lower  down,  in  the 
neighborhood  of  the  trochanters,  it  usually  splin- 
ters the  bone,  and  frequently  involves  the  ilio- 
femoral articulation.  Such  injuries  are  of  the 
mos1  serious  character,  and  are  usually  consid- 
ered fatal.  It  is  a  question  <>t'  much  moment, 
to  inquire  how  can  modern  Burgery,  with  all  <»t 
its  appliances,  improvements  and  experience,  as- 
sist in  Baving  the  life  and  limb  of  such  Beriously 
wounded'.''  Within  a  lew  years  the  rule  for  all 
compound  fractures  of  the  lemur  was  amputa- 
tion of  the  limb;  but  the  statistics  from  military 

hospitals    in     time    of    war    are    so    frightful — hut 

few  successes  for  the  numbers  treated — that  it 
was  naturally  suggested  that  the  risks  could  not 
he  materially  increased  by  letting  the  patierri 
take  the  chances  with  his  limb  <>n;  when,  it'  his 

lite  was  Baved,  it  would  he  with  and  not  with- 
out bis  leg.  'This  has  settled  down  into  a  oon- 
vieiion  lor  fractures  of  the  upper  third  of  the 
lemur,    which    are    now    treated    without     ampuia- 


1  N FF.RI  OR    KXTRF.M [TIES.  -'!'•  »'•  I 

tion,  inasmuch  as  nearly  every  amputation  in 
the  neighborhood  of  the  trochanter,  and  all  at 
the  hip-joint,   are   fatal. 

If  we  arc  assured  that  the  ball  lias  crushed 
the  head  of  the  bone,  then  the  operation  of  rc- 
section  offers  the  beat  prospects  oi'  stiecess  for 
the  patient;  but  it  docs  not  always  follow  that 
this  diagnosis  can  be  clearly  made  out,  if  the 
signs  of  intra-capsular  fracture  be  not  present. 
Military  surgical  experience  shows,  that  a  frac- 
ture of  the  upper  portion  of  the  shaft  of  a  bone 
does  not  necessarily  extend  into  the  head;  and 
met  verm.  Unless  the  junction  of  the  epiphysis 
with  the  shaft  is  struck,  the  fracture  is  more 
likely  to  be  confined  to  a  centre  of  ossification  ; 
so  that,  in  the  thigh  as  in  the  arm,  a  blow  just 
bel«>w  the  trochanter  will  not  usually  fracture  the 
head  of  the  femur.  When  the  joint  is  opened 
and  the  head  of  the  bone  fractured,  the  wound 
should  be  enlarged,  or  an  opening  made  into  the 

joint    from    the    outer    side    of  ibe    hip.    by   which 

the  fractured  head  might  be  removed. 

If  any  success  is  hoped  for.  those  cases  alone 
should  be  selected  in  which  neither  blood-vessels 
or  nerves  are  injured,  nor  the  soft  parts  exten- 
sively torn.  If  all  or  any  of  such  are  injured, 
where    experience    teaches    us   that    the    chances 


Km  QUNSHOI   ivu  im>   OS  Tin:   BIP. 

from  successful  resection  arc  more  than  doubtful, 
do  qoI  have  recourse  to  amputation,  which  is  bo 
certainly  fetal,  bui  lei  the  patient  live  his  few 
remaining  hours  or  days  without  being  haunted 
by  the  ghost  of  a  useless  operation.  Should  he 
revive  the  reactionary  Btage,  and  still  retain  a 
good  pulse  and  comparatively  unshattered  consti- 
tution, then  a  secondary  operation  might  give  a 
chance  <>l'  success.  In  the  Crimean  service,  n<> 
amputation  in  the  vicinity  of  the  hip-joint  was 
BUCCessful — every  individual  case  died.  This  only 
corroborates  the  experience  of  other  campaigns, 
and  also  -hows  the  inutility  of  such  mutilations. 
When  death  from  a  crushed  thigh-joint  is  inevi- 
table, it  is  hardly  humane  to  amputate  under  the 
plea  of  giving  to  the  patient  the  benefit  of  the 
chances  which  experience  teaches  us  are  uugatory. 
As  regards  resections  in  suitable  cases,  the  re- 
port is  a  little  more  satisfactory.  Of  bLx  resec- 
tions performed  by  the  English  surgeons  in  the 
Crimea,  one  was  Bucces&ful,  and  the  condition  of 
all  operated  upon  was  made  more  comfortable. 
Had  the  conveniences  for  treatment  been  greater 

and    the  general    sanitary   condition    of  the   troops 

better,  with  less  pyaamia,  hospital  gangrene,  chol- 
era and  scurvy,  much  better  results  mighl  have 
been   obtained.     Some  of  the   cases    were   doing 


GUNSHOT    INJURIES    OP   THE    HIT.  401 

well,  with  every  prospect  of  final  success,  when 
they  were  swept  off  by  one  of  the  above  diseases. 
In  amputations  at  the  hip-joint,  all  the  cases  died 
speedily. 

In  cases  of  resection,  the  greatest  difficulty  lies 
in  the  after-treatment.  As  it  is  not  expected  to 
restore  a  perfect  limb,  no  good  result  can  he  ob- 
tained by  using  violent  extension.  The  leg,  how- 
ever, must  be  fixed  to  facilitate  those  movements 
in  the  changing  of  position,  which  are  necessary 
to  the  patient's  comfort.  A  long,  straight  splint 
is  used  for  this  purpose  by  some  surgeons,  whilst 
the  incline-plane,  or  Smith's  anterior  splint,  which 
I  would  much  prefer,  is  depended  upon  by  others. 
Some  have  bandaged  the  limb  to  the  sound  one, 
and  speak  of  it  as  a  good  mode  of  support. 
Water  dressings  compose  the  local  treatment. 

Baudens  succeeded  in  saving  both  Kmb  and  life 
in  eases  in  which  compound  fractures  of  the  upper 
half  of  the  thigh  were  treated  without  operation. 
Consolidated  and  useful  limbs,  with  hut  little 
deformity,  are  reported  as  having  been  saved. 
By  the  use  of  the  fracture-box  and  incline-plane, 
he  succeeded  in  curing  a  compound  fracture  on  a 
level  with  the  trochanter:  saving  a  useful  limb, 
although  he  had  extracted  two  inches  of  the  shaft 

of    the    femur.      His    experience    proves    that    om- 

84 


4u_'  on   of  Tin:   hip-joint. 

■ 
pound    comminuted    fractures   of  the   upper  half 

of  the  thigh  are  not  so  fatal  when  attempts  are 
made  to  save  the  Itmh  as  when  the  thigh  is  ampu> 
The  experience  of  Burgeons  derived  from 
the  wounded  of  the  army  of  the  Potomac  would 
establish  a  similar  course  of  treatment,  as  excel- 
lent limbs  were  saved  where  fractures  had  <><•- 
curred  in  the  upper  third  of  the  femur,  whilst 
amputations  in  the  neighbor! d  of  the  trochan- 
ters met  with  the  usual  fatality. 

As  the  resection  of  the  hip  is  so  much  more 
successful  when  performed  for  disease  than  for 
injury,  it  has  been  suggested  by  surgeons  of  expe- 
rience  that  an  exception  t<>  the  rule  of  immediate 
tions  be  made  I'M'  tin-  hip-joint,  and  that 
such  cases,  even  the  most  suitable  for  the  opera- 
tion, be  deferred  until  suppuration  is  well  estab- 
lished. For  hip-joint  resections,  it  is  said  that 
nothing  is  lost  by  this  delay,  whilst,  on  the  con* 
trary,  there  may  be  a  chance  of  saving  the  limb 
without  an  operation.  Larrey,  in  1812,  reported 
six  cases  of  gunshot  fractures  of  the  neck  of  the 
femur,  with  three  cures:  showing  that  the  pros* 
peets  are  not  altogether  hopeless.  When  the 
patient  is  in  a  measure  placed  in  a  similar  condi- 
tion to  those  affected  with  diseases  of  the  bones, 
his  prospect  for  a  successful  resection  appears  to 


RESECTION    OP    THE    HIP-JOINT. 


4U3 


be  improved.  Bandens  says,  that  as  the  resection 
of  i lie  hip-joint  only  succeeds  as  a  secondary 
operation,  attempts  should  first  be  made  to  save 
the  limb. 

We  preface  the  following  table,  taken  from  Ar- 
mand's  Histoire  Medico- Chirurgicale  de  la  Guerre 
de  (  rimee.  with  the  suggestion  that  any  surgeon 
who  lias  ever  had  a  successful  case  of  resection  at 
the  hip-joint  lias  always  been  eager  to  publish  it; 
whilst  many  have  been  disposed  to  hide  their 
misfortunes  from  the  public,  so  that  the  tables, 
showing  tlu-  relative  advantages  of  primary  and 
secondary  resections,  appear  in  their  very  best 
light 

PRIMARY   RESECTIONS  AFTER  GUNSHOT  W0TTNDS. 


<  Iperat*  >1 
Upon. 


Deal  be. 


Larrey.     (  Volume  '■'>.  Clinique) 

.1.  Cooper.     (Dictionary  i 

(Relatione  'In  Siege  d'Anvurs  i>;ir 

M.  H.  Larrej  I 

Hotin.     (Memoirea  de  Medicine  el  de  Chi- 

rurgie  Militaires) 

Sedillot.    i  \  11  n :ilc-  de  In  Chimrgie  Francaise 



Ghiyon.     (Expedition  do  Churchill, 

i  Journees  de  Juin,  1848) 

Gtabiot.     (These  d<    MontpelHer,  1840) 

French  Crimean  Service 

McLcnd.     (Crimean  War  > 

Stromjei 


I 


*  Tlii-  <ful      -■■  was  found,  after  the  articulation  had  been  laid  open,  not 

oiteiirliiiir  within  t\\>-  joint,  but  •■•niflned  without  the  cwpsnlo;  and 
we  are.  therefore,  Justified  in  the  belief  that  the  caae  irould  have  done  equally 
well  without  lb 


-40-4 


!  0UNI1    FRACT1  RES. 


N'DARY    RESECTIONS    VFTER    01  SSHOT   WOUNDS. 


iniqua,  volume  5) 

(lutliric.     (Clinic  rolume  5) 

(  Bull<  tin  'I'  - 

rolame  3  

i ri..'«-  de  Jain.  1848) 

9  Juin.  I  •  I'     

Vidal.     (Traite  de  Chirorgi 

Uounii  r.    (I  

1.    '"II  antinople,  1854) 

(Ci  imean  War) 


upon. 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

3 

1 

1 

•■ 

12 

i 

Deaths. 


It  has  been  suggested,  thai  it'  the  patient  who 
baa  been  operated  apoti  could  have  facilities  fbi 
slinging  the  whole  body,  ii  would  afford  many 
advantaged  in  the  management  of  excisions  of  the 
hip-joint. 

A  compound  fracture  in  the  upper  third  of  the 
thigh  should  be  t rented  in  every  respect  as  it' 
in  the  arm.  Unless  the  leg  is  so  mangled  tliat 
an  amputation  is  an  net  of  necessity,  it  should 
not  be  thought  of.  We  have  already  said  that,  in 
field  military  Burgery,  amputation  near  the  trunk 
is  Bynonymoua  with  death.  The  treatment  must 
commence  on  the  battle  field  by  proper  transport 
tation;  the  judicious  removal  of  fractured  limbs 
important  as  an  operation,  and  any  neglect 
in  this  department  will  deprive  the  wounded  man 
of  all  hope  of  retaining  his  limb,  or  of  having  hid 


COMPOUND    FRACTURES.  405 

life  saved;  We  will  carefully  remove  all  loose 
and  movable  spieujse,  dilating  the  wounds  if  ne- 
cessary to  i'aeilitate  the  thorough  removal  of  all 
foreign  bodies.  Until  suppuration  is  well  estab- 
lished, the  limb  is  kept  in  an  easy  position  and 
surrounded  witb  cold  applications.  All  tight,  re- 
tentive bandages  are  to  be  rejected,  as  they  inter* 
fere,  with  topical  antiphlogistic  applications.  Dis- 
pense with  bandages.  On  the  eighth  or  tenth 
dav.  when  tin1  reactionary  Btage  has  passed,  the 
wound  is  again  to  be  examined  for  foreign  bodies, 
and  all  portions  of  bone  which  may  have  become 
separated  by  the  inflammatory  process  must  lie 
removed;  or,  as  sequestra,  they  will  become  in- 
corporated in  the  new  osseous  formations,  and  be 
the  cause  of  much  trouble  and  suffering. 

In  all  compound  fractures,  with  much  loss  of 
bone,  it  is  always  injurious  to  attempt  to  obtain 
a  limb  of  equal  length  with  the  bound  one.  It 
cannot  be  done  and  the  chafing  and  annoyance 
of  splints  and  tight  bandaging  may  react  wry 
seriously,  if  not  fatally,  upon  the  constitution. 
The  drst  thing  to  be  attended  to  is  to  prepare 
the  facilities  for  treating  such  a  fracture.  If  we 
are  striving  foi  successful  results,  we  must  not 
expeel  to  obtain  them  if  a  patient,  with  a  coin- 
pound  fracture  of  the  thigh,  i>  being  treated  upon 


J';  '■  COMPOUND   PRAC1 

round  or  is  lying  upon  a  little  straw.  !!<• 
must  have  a  proper  bed  :m<  1  ;i  good  firm  mat- 
tress, prepared  with  :i  bed-pan  hole  for  facilitat- 
ing nature's  daily  wants  without  the  necessity  of 
moving  him. 

I  pon  this  the  patient  ia  placed,  lying  on  his 
back,  with  the  l%g  extended.  Two  long  straps 
of  diachylon  plaster  are  attached  to  the  Bid 
hia  leg  from  the  knee  bo  the  ankle;  tbey  form  a 
loop  under  the  foot,  and  a  weight  is  Bwung  from 
this  over  the  Soot  of  the  bed.  This  will  be  >u\Y\- 
eient  to  tire  the  muscles  and  make  the  necessary 
degree  of  extension;  or  the  limb  might  be  loosely 
attached  to  a  long  thigh-splint.  The  tumefaction 
roller  is  inadmissible,  and  strips  of  adhesive  plas- 
ter, or  strips  of  bandage,  will  secure  the  limb  t<> 
the  splint,  and  at  the  same  time  leave  the  wound 
open  for  inspection  and  dressing.  For  the  first 
week  oi-  ten  days,  this  will  Ik-  ;ill  the  apparatus 
aeeded.  A-  tin'  case  advances,  splints  may  be 
more  methodically  applied  by  using  long  inner 
and  outer  >[ilints  of  light  hoard,  well  padded  with 
loose  cotton,  and  secured  in  position  by  bands  of 
adhesive  plaster  <>r  with  tapes.  The  «osH«Sar- 
extending  hands  an'  made  by  adhesive  strips, 
attached  to  the  sides  of  the  leg  and  carried  under 
the  too,,  where  they  are  secured  to  the  end  of  the 


COMPOUND    FRACTURKs.  407 

splint.  Allow  the  ends  of  the  bones  to  fill  up  the 
void  made  by  the  extraction  of  the  spicules,  as 
this  hastens  consolidation. 

A  better  method  of  treating  fractures  of  the 
thigh  is  in  the  use  of  Smith's  anterior  splint,  by 
which  the  limb  is  suspended.  This  splint  is 
formed  of  a  strong  iron  wire  (three-sixteenths  of 
an  inch)  bent  in  the  form  of  a  parallel  logramj  as 
long  as  the  limb,  and  five  inches  wide  Cross- 
pieces  of  the  iron  prevent  the  sides  from  collapsJ 
ing,  and  are  also  used  for  suspending  the  limb. 
This  wire  splint  is  placed  upon  the  anterior  sur- 
face (^'  the  limb.  Whilst  traction  is  being  made 
upon  the  loot  by  an  assistant,  which  removes  ail 
shortening,  the  splint  is  secured  by  enveloping 
the  entire  limb  in  a  roll  of  bandage,  omitting  the 
bandage  at  the  point  where  the  ball  lias  pene- 
trated. The  limb  is  then  suspended  two  or  three 
inches  above  the  bed,  by  passing  cords  from  the 

upper  and  lower  cross-wires  of  the  splint,  which, 
uniting  in  a  single  cord,  is  attached  to  the  ceil- 
ing or  top  of  the  bedstead.  With  the  limb  thus 
suspended,   the  patient   may   move  about   in    the 

bed  at  pleasure,  without  tear  of  disturbing  the 
adjustment  or  giving  himself  pain.  A-  the  roll 
of  bandage  has  been  omitted  at  the  site  of  the 
wound.  loc;d  applications  can  he  daily  made  and 
the  parts  duly  inspected. 


inv  oohpound  PBAorvmn 

^^^ i 1 1 1  the  exception  of  the  mechanical  appli- 
ances Por  tlic  broken  bone,  the  case  is  treated  as 
for  :i  long-continued  Buppurating  wound,  by  avoid- 
ing, in  iill  cases,  depletion  and  by  giving  liberal 
diet.  Manv  of  these  cases  will  die;  bul  if  we 
have  facilities  in  a  well-ventilated  and  well-organ- 
ised hospital,  we  will  have  the  satisfaction  of  Bar- 
ing Bome  of  the  patients   submitted  to  our  care. 

In  fractures  of  the  middle  and  lower  third  o( 
the  thigh,  not  implicating  the  knee-joint,  the 
question  will  again  occur:  whal  course  is  to  be 
pursued  with  them?  These  arc  still  very  serious 
cases,  ami  arc  classed  wiili  those  of  the  Qpper 
third.  Where  attempts  are  made  to  gave  them, 
;i~  recommended  by  Guthrie,  the  fatality  will  not 
he  very  dissimilar  to  fractures  nearer  the  trunk, 
and  the  moderate  success  which,  under  the  very 
beat  circumstances,  we  will  obtain,  will  depend 
upon  the  State  of  health  of  the  suH'erer  and  the 
conveniences  for  treatment. 

There  arc  cases  which  often  appear  so  trivial — 
only  a  small  bullet  hole  leading  to  the  crushed 
hom — that  it  seems  barbarous  surgery  to  con- 
demn the  limb  without  an  attempt  ;:t  saving  it. 
The  young  military  surgeon  expects  much  from 
conservative  surgery  in  such  cases.  We  are  in- 
formed   by   the    experienced,   that    this    striving 


AMPUTATE   COMPOUND    FRACTURES.  40(.> 

after  conservatism  is  the  main  cause  of  the  heavy 
mortality. 

Surgeons  generally  are  not  prepared  to  believe 
how  hopeless   compound  fractures   of  the   thigh 
are,  until    the  unwelcome   truth   is   forced    upon 
them  by  an  ever-recurring  experience,  that  mauy 
lives  are  sacrificed   to   attempts  at    Baving  these 
broken  limbs.     In  civil    surgery,   or  with   every 
facility  in  military  hospitals,   we    should    attempt 
to  save  the  limb — it  is  the  proper  course  to  pur- 
sue :   hut  on  the  battle  field,  with  the  deteriorated 
material  upon  which  we    are  operating,  and    the 
poisoned  atmosphere  of  the  wards  into  which  tin1 
patient  is  to  be  carried,  it  is  a  fatal  error.     Mil- 
itary   surgeons  must    abandon    their  conservative 
intentions    to    expediency.     It   is    for    such    eases 
that   primary  amputation  offers  the  best    chances 
tor  life.     In  rejecting  amputations,  we   lose   more 
Lives    than   we   save    limbs.      As    a    rule,    amputa- 
tions are  less    hazardous  the   greater  distance  we 
Operate  from  the  trunk:  and  the  reason  why  am- 
putation-, are    urged    for   compound    fractures   of 
the  lower  and   not    upper  portions  of  the  femur 
i<.    thai    the   ehances    being    similar  withoul    it. 
amputations    are    ninth    lc~<   fatal    in    the   lower 
than    in  the  upper  half  of   the  thigh.     Attempts 
at    saving   limbs,   after   the    battles   on    the    1'" 


41 U  AMPUTATE    C0MP01  M»    RBAOXI  RE8. 

tomac,  confirm  the  above  experience.  Too  few 
primary  amputations  were  performed  upon  the 
lower  portion  of  the  thigh,  and  the  result  was 
a  heavy  mortality  among  this  class  of  wounded. 

Resection  of  the  shaft  of  the  femur  foe  a 
crushing  of  the  bone  has  been  often  recom- 
mended, and  as  often  practiced:  but  the  experi- 
ence  of  tatter  years  discourages  its  performance, 
as  the  operation  is  more  serious  than  the  con- 
cfttion  for  which  the  remedy  is  used.  When 
the  splinters  of  bono  are  removed,  there  is  con- 
siderable  space  tor  the  play  of  the  rough  edges 
remaining,  which,  therefore, give  but  little  trouble. 

Should  we  attempt  to  save  a  fractured  thigh 
in  its  lower  third,  we  may  use  either  the  straight 
splint  or  the  double  incline-plane.  The  latter 
is  much  the  more  comfortable  position  for  the 
patient,  but  has  the  disadvantage  of  promoting 
the  burrowing  of  pas,  which,  in  working  its  way 
down  the  limb,  may  dissect  passages  for  itself 
as  far  as  the  buttock,  and,  by  its  multiplied 
openings,  cause  much  annoyance  us  well  as  much 
destruction  to  bones  and  muscles.  The  anterior, 
wire  splint  of  Smith  is  found  most  suitable  in 
these  fractures.  Surgeons  in  the  Crimea  often 
had  cause  to  regret  attempts  at  savin--  fractured 
thighs,  but  never  regretted  an  early  amputation. 


KNEE-JOINT    INJURIES.  411 

When  the  knee-joint  is  implicated  in  a  shot 
wound,  or  cut  open  by  a  shell,  with  injury  to 
the  head  of  the  tibia  or  femur,  experience  has 
shown  that,  however  trivial  the  wound  may  ap- 
pear, if  the  synovial  sae  be  entered,  and  air  be 
admitted,  or  a  foreign  body  lie  within  the  joint, 
violent  synovitis,  with  great  pain,  swelling  and 
heat,  and  with  excessive  inflammatory  fever,  will 
come  on  alter  twenty-four  or  thirty-six  hours. 
Should  the  patient  survive  the  inflammatory 
stage,  erysipelas,  pyaemia  or  hectic  will  ultimately 
destroy  life:  and  although,  on  the  other  hand, 
the  effusions  may  he  absorbed,  and  an  anehylosed 
hut  useful  limb  saved,  it  is  a  very  rare  occur- 
rence. If  the  soft  parts  are  not  much  lacerated, 
or  the  flood-vessels  and  nerves  behind  the  joint 
injured,  such  cases  are  well  adapted  for  resection, 
and  excellent   results  are  obtained   in   practice. 

A  straight  or  elliptical  incision  over  the  an- 
terior portion  of  the  joint,  across  its  entire 
diameter,  will  expose  the  interior,  and  enahle 
the  surgeon  to  remove  (he  foreign  bodies,  what- 
ever they  may  he.  and  with  them  the  head  of 
the  injured  hones,  'flic  section  of  the  hones 
should  he  made  in  such  a  way  that  the  surfaces 
will  adapl  themselves  to  each  other — usually  the 
patella   is   removed.      When   the  externa]    wound 


KM  ,i:-.l.ii\  (     I.N.I  I    R 

i>  closed  by  Botures,  anion  by  the  tirsl  intention 
may,  to  a  <  «n :ii n  extent,  be  obtained.  In  the 
successful    cases,    the    b  entually    become 

firmly  united,  and,  with  an  anchylosed  joint, 
the  patient  retains  a   useful   Limb. 

Ai'i.t  the  resection,  a  1  < >  1 1 ^r  splint  upon  the 
back  of  the  leg,  reaching  from  the  buttock  to 
the  heel,  is  all  the  apparatus  required,  whilst 
oold  water  dressings  alone  are  applied  around 
the  joint.  In  cases  of  resection,  the  sui 
must  ii"i  expect  quick  union  in  the  wound,  as 
that  does  not  often  occur  in  military  surgery. 
A  tedious  suppuration,  the  formation  of  nume- 
rous absc<  and  often  the  exfoliation  of  por- 
tions of  bone,  is  the  rule,  requiring  care  and 
judicious  management  to  obtain  a  final  success  ; 
many  of  those  operated  upon  being  lost  by  the 
action  of  those  deleterious  causes  which  act  in- 
juriously   upon    all    wounds   in    military    hospitals. 

When  attempts  are  made  to  save  the  limb 
in  what  we  Buppose  to  be  a  trivial  or  doubtful 
case  of  knee-joint  injury,  we  shduld  follow  the 
routine  of  the  antiphlogistic  treatment.  In  a 
Bingle  puncture  of  the  capsule,  even  when  Byno- 
via  has   escaped,   the  orifice  may   heal   \<\    quick 

union.        When     local     inflammation    ensues,    and 

run.-  such  an  acute  course  that    the  free  applies- 


COMPOUND    FRACTURE    OP    THE    T,KC  4T3 

tion  of  leeches — twenty  to  fortj  to  a  limb — does 
not  quell  the  inflammation,  and  we  are  led 
to  infer  that  pus  lias  formed  within  the  joint, 
the  articulation  should  be  largely  opened,  and 
the  joint  thoroughly  cleansed,  whether  wo  resed 
the  heads  of  the  bones  or  not.  There  is  no 
longer  injury  from  the  admission  of  air,  whilst 
there  is  serious  fear  of  destruction  of  the  carti- 
lages should  the  colleetion  of  pus  he  retained'. 
This  tret-  opening-  of  the  articulation  may,  in 
some  cases,  obviate  the  necessity  lor  secondary 
ions,  as  excellent  results  have  been  obtained 
by  this  apparently  hold  surgery — the  patient  liv- 
ing his  life  and  limb,  with  an  anehylosed  joint. 
The  effect  of  this  incision  in  allaying  the  general 
irritation   is  said   to  he  marked. 

The  course  which  -will  he  pursued  with  a  frac- 
ture of  the  bones  of  the  leg  must  depend  upon 
the  extent  of  injury  to  the  soft  parts,  and  also 
the  facilities  at  hand  for  treating  Fractures.  Our 
main  object  is  always  to  save  life.  and.  it'  possi- 
ble, the  limb  also:  hut.  in  our  too-grasping  dis- 
position,    we    must    be    very    guarded    how    we 

jeopard   the   one   to   save   the   other.      It    is    in    this 

respect  that  military  surgery  is  so  very  differ*  at 
from  civil  practice.  We  are  continually  com- 
pelled   to   sacrifice    limbs   lo   expediency,   when, 


Ill  COMPOUND    rRACTTTRfi    OF    THE    LEO 

under  more  favorable  conditions,  we  would  not 
hesitate  to  practice  conservative  surgery.  To 
introduce  ;i  Bingle  example:  where  ;i  long  and 
tedious  transportation  becomes  i  ry  utter  :i 

battle,  ii  would  be  expedient  to  amputate  mncti 
more  freely  than  we  would  do  were  there  hos- 
pitals in  the  immediate  neighborhood  of  the 
battlefield  where  the  wounded  could  be  treated. 
I  low.  for  instance,  could  we  transport  with  any 
chance  of  Buccess  n  resected  joint,  such  as  the 
shoulder,  or  a  gunshot-fractured  thigh  or  leg? 
I'udt'i-  Midi  circumstances,  an  amputation  would 
give  the  patient  a  much  better  chance  for  lite, 
which  should  always  be  the  main  object. 

When  facilities  offer  for  attempting  the  pres- 
ervation of  a  fractured  leg,  the  same  precautions 
are  taken  as  iu  other  fractures  for  removing 
immediately  all  loose  or  very  movable  fragments 
of  hone.  The  limb  is  placed  in  a  fracture-box, 
or   upon    the   double    incline-plane,  and    by    the 

constant    application   of  cold   water,  whilst    we   use 

those  remedies  already  suggested  for  keeping 
down  an  excessive  reaction,  we  watch  the  march 
of  the  case,  and  meet  the  various  complications 

as   they  arise,  hy  the  rule-  of  practice  which   have 

he. mi  already  frequently  discussed.  Should  mor- 
tification   appear  in    the  wound  a   few  days  after 


FROST-BITE.  4  1  5 

tho  injury,  wo  will  find  the  only  moans  of  safety 
in  early  amputation. 

Resections  of  the  ankle-joint  have  not  been 
followed  by  that  success  which  has  characterized 
operations  upon  the  larger  joints,  especially  the 
knee  and  the  elbow;  It  is  recommended  as  a 
conservative  measure,  but  is  seldom  practiced. 
When  gunshot  injuries  occur  about  the  ankle. 
crushing  the  bones,  excision  offers  but  a  meagre 

resource.  Mortification  often  follows  such  inju- 
ries, and  amputation  holds  out  stronger  induce- 
ments for  immediate  and  subsequent  benefit. 

Fr.usr-I'.rn:. — Anions  the  affections  of  the  ex- 
tremities which  surgeons  in  the  field  are  called 
upon  to  treat,  during  the  inclemency  of  the 
winter's  campaign,  are  those  occasioned  by  ex- 
posure io  cold  and  moisture.  During  the  winter 
months,  an  army  suffers  from  these  accidents  in 
proportion  to  the  privations  which  they  arc  com- 
pelled to  undergo — for  well  led  and  well  clothed 
troops  do  not  readily  yield  to  the  injurious  influ- 
ences of  exposure. 

During    the    Crimean    war,    the    two    winters 

which    the   allied   army  spent    before   Bebastopol 

very  different  in  character.     The  winter  of 

.  was   not    \cry  colli,  hut  was  a   season  of 


116  FROST-BITE. 

contiuued  rain;  the  soldiers  were  literally  Jiving 
in  the  mini,  with  wet  clothes,  which  for  weeks 
they  had  do  means  of  drying;  at  the  same  time, 
the  difficulty  of  procuring  supplies  was  ao  great 
that  their  means  of  subsistence  kept  them  just 
above  starvation.  Bleeping  in  wet  boots  as  long 
as  the  boots  were  whole  enough  to  remain  on,  and 
the  continued  masceration  of  the  feel  in  snow 
ami  ice-water  caused  a  gradual  diminution  of  the 
circulation  and  vitality  <>i"  the  toes  and  feet. 
Very  short  allowance,  unusual  exposure,  and 
very  indifferent  shelter,  more  than  counterbal- 
anced the  absence  of  a  very  low  temperature, 
and  the  result  was  that  extremities,  which  could 
barely  be  kept  alive,  would  be  given  over  t<> 
disease  under  a  temperature  which  would,  undei 
other  conditions,  be  innocuous.     The  feel  and  toes 

would     become    swollen    and    udeinatoiis,    with    a 

feeling  of  ten.- ion  which  gave  much  uneasiness 
during  the  day,  with  Buch  an  increase  of  pain 
toward  oight  as,  in  many  instances,  to  prevent 
deep ;  the  parts  would  be  discolored  of  a  brown- 
isli  red  hue.  In  more  serious  cases,  blisters 
would  form  upon  the  discolored  surfaces,  beneath 
which  blood  would  extravasate.  The  dFying  ami 
blackening  of  this  would  simulate  mortification  so 
closely  as  to  he  mistaken  by  the  careless  observer; 


FROST-RTTK.  \  1  l 

the  peeling  oft'  of  this  blackened  pellicle  -would. 
however,  expose  either  a  new  skin  or  an  ulcer- 
ated surface.  Tn  feeble  constitutions,  the  parts 
attacked  by  this  low  inflammation  break  down 
into  sloughing  ulcers,  characterized  in  their  future 
march  by  ehronicky,  and  an  inactivity  in  the  for- 
mation oi'  healthy  granulations;  also  an  excessive 
secretion  of  a  highly  offensive,  ichorous  pus,  with 
pale,  greyish,  exuberant,  irritable,  very  painful 
and   bleeding   granulations. 

Like  burns,  the  effects  of  cold  show  various 
degrees  of  gravity,  from  the  redness  and  putiiness 
of  a  toe,  through  blistering  of  the  surface,  and 
the  formation  of  superficial  ulcers,  to  the  com- 
plete mortification  of  extremities  and  putrescent 
liquefaction  of  the  soft  parts,  with  the  usual 
systemic  irritation,  general  depression,  and  intes- 
tinal complications. 

A   second  variety  of  Frost-bite  was  well  exem- 
plified  in  the  Crimea  during  the  winter  of  1 
'")«').      At    this    period,  the    soldiers    were    better 

clothed    and     W'd,   all     the    comforts    of    army    life, 
at    their    disposal,   and    the   hygiene  of  the 
camp  was  in  every  reaped  good. 

The  temperature  of  this  winter  was  so  extreme, 
that  warm  clothing  could  not  retain  the  degree 
of  heal  necessary  to  support    life  in   the  extremi- 


11^  PKOBT-BTTE. 

\\  li<»  were  mwli  exposed  first  loal 
all  sensation  in  their  feet,  bo  thai  ii"  feeling 
would  be  imparted  t<»  the  foot  upon  touching  tit** 
ground,  and  then  found  some  difficulty  in  walk- 
ing, or  even  in  supporting  the  erect  posture.  The 
feet,  upon  examination,  would  be  round  cold, 
livid,  mottled,  slightly  swollen,  hard,  oedematous, 
and  without  sensation.  Tin-  continued  influence 
of  cold  would  destroy  the  limb,  causing  it  t<> 
shrivel  and  become  dark.  In  time,  a  line  <>t'  de- 
markation  would  form,  and  the  slow  process  of 
separation  commence,  leaving  a  chronic,  fungus, 
sensative  ulcer,  from  which  a  foetid  pua  would 
lie  continuously  discharged  for  months.  As  the 
fibrous  tissues  resist  mortification,  they  retain 
dead,  blackened  bonea,  which  protrude  from  the 
face  of  tin'  ulcer — a  Bource  of  much  annoyance, 
keeping  up  irritation,  causing  abscesses  in  the 
vicinity,  and  extending  the  mischief  to  contigu- 
ous bones.  Should  any  attempt  be  made  to  re- 
move these  protruding  and  hanging  phalanges, 
constitutional  irritation,  with  increased  pain,  and 
a  fungus  condition  of  the  ulcer,  if  not  gangrene, 
were  sure  to  follow. 

The  treatment,  which  is  found  most  useful   in 
of   frost-bite,    would    be    of  a    stimulating 

■ 

character,  avoiding  studiously  the  application  of 


KKOST-1UTE.  41i> 

heat  in  any  Form.  Where  the  parts  are  swollen, 
painful  and  discolored,  frictions,  with  simw  or  ire 
water,  is  the  popular  mode  of  treatment,  which 
indications  we  carry  out  by  local  applications  of 
spirits  of  camphor,  turpentine,  or  sugar  of  lead 
and  laudanum,  or  by  painting  the  parts  with 
tincture  of  iodine  or  a  solution  of  nitrate  <>!' 
silver.  Under  Birch  applications,  the  local  symp- 
toms will  gradually  disappear.  For  the  more 
serious  grades,  with  ulceration,  stimulating  and 
narcotic  applications  will  be  found  the  most 
useful,  although  a  tedious  cicatrization  Will  ac- 
company the  most  judicious  treatment. 

When  mortification  threatens,  never  use  warm 
poultices,  which  I  have  seen  applied  in  such 
cases  —  a  certain  means  of  insuring  an  extensive 
destruction — hut  by  frictions,  with  cold,  stimu- 
lating substances,  try  bo  excite  new  action  in 
tiie  parts,  and  should  the  genera]  system  have 
been  much  depressed,  stimuli  and  nourishing 
food,  with  the  tonic  preparations  of  iron,  should 
he  administered.  Until  the  line  of  separation 
between  the  dead  and  living  parts  is  well  es- 
tablished, and  the  neighboring  tissues  have  lost 
their  discoloration,  swelling  and  induration,  no 
amputation  should  he  performed,  as  gangrene  is 
likely   to   follow    the   irritation    produced   by   the 


4  J < »  IHoST-lSITK. 

knife  in  such  diseased  tissues.  A.s,  however, 
these  -lowly  decomposing  masses  would  poison 
the  atmosphere  of  an  hospital  by  putrefactive 
emanations,  the  course  which  was  found  most 
successful  was  to  cut  away  the  dead  masses, 
and  remove  the  sloughs,  but  without  touching 
the  Living  Tissues. 

In  the  majority  of  cases,  those  Burgeons  who 
cut  off  the  bones  at  the  face  of  the  stump, 
leaving  nature  to  complete  the  cure,  had  the 
most  satisfactory  results.  Experience,  howev< t. 
shows  the  process  of  cicatrization  to  be  BO  slow, 
and  the  cicatrix  remains  so  Long  sensative,  that 
a  preferable  mode  is  to  amputate  in  healthy 
tissues,  a1  some  tittle  distance  above  the  well- 
defined  line  of  separation.  When  the  patient  is 
in  good  health,  or  his  system  has  been  prepared 
by  good  food  and  stimuli,  and  when  no  gastro- 
intestinal complications  are  engrafted  upon  the 
local  injury,  this  secondary  amputation  hastens 
the  cure. 

It  may  be  necessary  to  modify  the  form  of 
amputation  in  such  cases.  Where  the  toes  have 
all  been  destroyed,  the  line  of  mortification  is 
usually  found  as  extensive  in  the  sole  as  upon 
the  hack  of  the  foot,  which  prevents  the  usual 
Hap    from    being  taken    from    the   plantar   surface. 


WIIKX    AMPUTATIONS    NB0ES8ART.  421 

Iii  such  cases  it  is  better  to  perform  the  circu- 
lar amputation,  making  perpendicular  incisions 
on  the  sides  of  the  foot   to  facilitate  the  section 

of  the  bones;  and  as  the  bones  of  the  inner  side 
of  the  foot  are  much  more  extensive  than  those 
of  the  outer  side,  the  line  of  circular  incision 
should  he  oblique  to  allow  of  a  greater  extent  of 
soft  parts  on  the  inner  side  of  the  foot.  It  is 
not  necessary  to  follow  the  contour  of  the  joints 
in  making  these  amputations.  The  much  sim- 
pler plan  is  to  use  the  saw  rather  than  to  dis- 
articulate—  which  is  at  all  times  a  tedious  and 
troublesome  operation,  especially  when,  with  the 
mortification  of  the  anterior  portion  of  the  foot, 
the  lever  is  destroyed,  which  assists  so  materially 
in  exposing  the  articular  interspaces  for  the  pas- 
sage of  the  knife. 

We  have  often  referred  to  the  fact  that  am- 
putations will  ever  he  a  necessity  in  military 
surgery;  and,  according-  to  McLeod,  had  they 
been  more  freely  practised  in  the  Crimea,  a 
larger  number  of  lives  would  have  been  saved. 
It  was  tor  thai  reason  that,  in  the  distribution 
of  labor  in  the  field  infirmaries,  it  was  recom- 
mended that  the  surgeon  who  had  the  <rreatrsl 
experience,  and  upon  whose  judgment  most  re- 
liance   COUki    be    placed,    should    officiate    a>    exam- 


422  WIIKN    AMPUTATIONS    NEC]     SARY. 

in< r:   and   his  decision   1"'   carried   out    by  t) 
who  mav  possess  a  greater  facility  for  the  oper- 
ative manual. 

A  a  general  rule,  the  following  conditions 
necessitate  the  Loss  of  a  liml>.  viz:  When  an 
entire  limb  ia  carried  off  by  a  cannon  ball,  leav- 
ing a  ragged  stnnip;  or  when  a  limit  is  literally 
crushed  up.  although  still  attached  to  the  body, 
it  will  be  necessary  to  amputate  bo  form  a  good 
stump:  also,  if  ihf  principal  vessels  and  nerves 
are  torn,  even  without  injury  to  the  bone;  of 
it' the  soft  parts  are  niiirli  lacerated;  or  in  cases 
of  extensive  destruction  of  the  skin  —  as  such 
cases  offer  very  tedious  cures  if  cicatrization  is 
ever  obtained.  Au-ain.  in  severe  compound  tVae- 
tures,  and  often  in  apparently  simple  compound 
fractures,  where  experience  teaches  us  thai  al- 
though the  wound  may  appear  trifling  to-day,  in 
attempting  to  save  it  we  will  sacrifice  a  life  a 
few  days  hence,  imputation  is  compulsory  when 
mortification  of  the  limb  rapidly  follows  upon 
an  injury :  also  when,  in  compound  fractures  or 
perforated  joints,  the  profuse  discharge  or  the 
continued  irritation  threatens  s  fatal  issue;  again, 
where  joints  are  crushed,  and  where  resections 
are  not  admissible;  or  where  a  fracture  of  the 
shall    of   a    hone    extends    into   a    joint  :     also    in 


WHEN    AMPfTATIONS    NECESSARY.  42:; 

cases  where  secondary  hemorrhage  cannot  he  con- 
trolled by  the  Ligature,  or  by  any  other  hemos- 
tatic. Knowing  that  in  such  cases,  sooner  <>r 
later,  the  linih  and  life  will  be  jeoparded,  we 
must  anticipate  these  troubles  by   amputation, 

Military  surgeons  have  long  made  the  impor- 
tant division  of  amputations  into  primary  and 
secondary — a  division  of  great  practical  impor- 
tance, and  which  forces  itself  upon  our  notice 
by  the  relative  mortality  following  the  two  oper- 
ations. Amputations  for  direct  injury  are  styled 
primary:  those  required  for  cases  of  mortifica- 
tion, profuse  suppuration,  secondary  hemorrhage, 
or  lor  necroses,  are  called  secondary  or  mediate, 
mid  comprise  all  amputations  performed  after 
the  first  twenty-four  or  thirty-six  hours,  when 
reaction  has  set  in.  The  experience  of  every 
battlefield  shows,  that  the  mortality  following 
the  amputation  of  limbs  which  require  imme- 
diate operation  is  always  less  than  those  per- 
formed some  days  after  the  infliction  of  the 
wound  —  although  the  milder  cases  wore  those 
retained,  and  the  most  Bevere  those  selected  for 
immediate  operation.  As  all  military  surgeons 
recognise  the  propriety  of  amputating  condemned 
limbs  within  twenty-four  or  thirty-six  hours  after 
injury,  before    inflammatory   reaction  has  set   in. 


4-!l  WIIKN     AMl'l   TA  II  ;  Bfl  \KY 

the  aobjecl  requires  no  discussion.  The  rule  in 
military  surgery  is  absolute,  viz:  that  tfu  ampu- 
intni'i  knife  should  immediately  follow  tl><  co/ndemfttir- 
/,'■,,,  of  flu  Umb.  These  are  operations  for  toe 
battlefield,  and  Bhould  be  performed  at  the  fieW 
infirmary.  When  this  golden  opportunity,  be- 
fore reaction,  is  lost,  it  ran  never  be  compen- 
sated  for. 

The  rule  in  performing  primary  amputations 
is.  fee  operate  as  far  as  possible  from  the  trunk, 
as  every  inch  diminishes  the  risk  to  life.  This 
rule  is  so  general,  that  when  an  amputation  can 
be  performed  at   a  joint,   never  amputate  higher 

Upj     for    instance,    if    an    amputation     cannot     be 

performed  upon  the  uppor  pari  of  the  leg,  re- 
move the  limb  at  the  knee-joint  rather  than 
amputate  the  thigh. 

In  secondary  amputations  it  may  not  be  expe- 
dient to  follow  this  rule;  necessity  or  the  desire 
to  save  life,  which  is  always  paramount,  may 
compel  us  to  amputate  al  a  distance  from  the 
injury,  as  in  cases  of  mortification.  Gangrene 
should  seldom,  however,  require  a  secondary  am- 
putation, if  the  rules  for  primary  amputation  be 
followed,  viz:  of  removing,  at  once,  all  limbs  in 
which  the  blood-vessels  and  nerves  arc  exten- 
MiVely  injured  in  connection  with  the  crushing 
of  the  bon< 


. 


WHEN    AMPUTATIONS    NECESSARY.  4'2o 

When  mortification  attacks  a  limit,  it  will  bo 
known  by  change  of  color  in  the  skin.  When 
it  occurs  in  the  leg,  which  is  its  common  scat, 
the  foot  changes  from  the  natural  fiesh  color  to 
a  tallowy  or  mottled  white;  the  tissues  in  a 
measure  liquify,  arc  cold,  and  become  offen- 
sive—  breaking  up  into  more  or  less  extended 
sloughs,  saturated  with  an  ichorous  fluid.  This 
gangrenous  condition  may  stop  at  the  ankle, 
cither  above  or  below7  it,  depending  upon  the 
seat  of  injury;  or  it  may  creep  up  to  the  knee, 
where  it  equally  shows  a  disposition  to  limit  its 
extension.  When  the  ankle  limits  the  mortifica- 
tion, we  amputate  below  the  knee;  when  other- 
wise, above  it.  These  cases  are  usually  unsatis- 
factory, as  a  general  poisoning  is  soon  effected, 
and  the  stump,  wherever  made,  is  attacked  in  a 
few  days,  as  if  by  a  continuation  of  the  same 
gangrene. 

In  mortification  of  the  stump,  unless  it  be  in 
the  vicinity  of  the  ankle-joint,  a  second  amputa- 
tion is  not  admissible.  P>y  the  local  use  of  pure 
nitric  acid  to  the  mortified  surface,  or  the  concen- 
trated Labarraque's  chloride  of  soda,  or  pyrolig- 
ueoua  acid,  we  Btrive  to  limit  the  extent  of  the 
slough:  whilst,  with  carbonate  of  ammonia,  qui- 
nine,  brandy,  and    strong    food,    we    support    the 


HOW    AMPTTTATIO?  -    PKBFORM1 

- \- - 1 o 1 1 1  until  some  improvement  makes  its  appear- 
ance in  the  stump.     WTien  all  the  sloughs  have 

l n  eliminated  ;ui<1   the  stamp  has  commi 

i1   will   be   time   enough   to   remodel 
ill.'  old  amputation,  by  cutting  off  the  protruding 
.  which  ie  always   better   practice   than   per- 
forming a  —«-«-<  >  1 1  *  1  amputation. 

Having  condemned  a  limb,  we  should  wait  un- 
til the  nervous  shock  —  from  which  most  of  the 
wounded  Buffer — subsides,  and  then  give  chloro- 
form. Should  we  not  have  tin'  time  for  it-  proper 
inhalation,  we  may  i i ij<  <-t  a  half  grain  or  more  of 
morphine  auder  tin'  skin,  which  will  produce  a 
rapid  blunting  of  nervous  sensibilities;  and  in 
five  minutes,  or  even  in  less  time,  tin-  patient 
will  be  in  a  fit  condition  t<»  stand  the  operation 
with  the  leaal  degree  of  constitutional  Bhock. 

In  th<>  performance  <>l"  all  serious  operations, 
when  possible,  there  should  be  three  assistants. 
One  aid  gives  the  chloroform;  a  second  com- 
pres  i  main   artery,   which    is   much    better 

than  nsing  the  tourniquet — an  instrument  which 
ie  now,  in  a  great  measure,  discarded  from  prac- 
tice— and  a  third  holds  the  limb  and  supports  the 
flap  during  the  sectiop.  The  aid  wli<>  adminis- 
tered the  chloroform  during  the  incisions,  can 
assist  in   ligating  the  arteries.     Military  surg 


HOW    AMPUTATION'S    PERFORMED.  4^7 

prefer  the  circular  operation  to  tlic  flap,  wliicli 
they  onlv  use  in  the  exceptional  cases.  With 
the  circular  stump,  covered  onlv  by  skin,  there 
is  less  soft  tissue  to  suppurate  and  slouch,  and 
a  much  more  rapid  cicatrization  is  effected.  Ex- 
perience, which  lias  knag  recognised  the  utility  erf 
the  circular  operation  for  the  leg,  has  now  gener* 
alixed  it  as  the  most  useful  amputation  tor  the 
thigh  or  arm. 

Having  assigned  the  aids  their  posts,  and  seen 
that  all  the  necessary  instruments  which  may  1><> 
needed  are  at  hand — tor  a  surgeon  should  never 
commence  an  operation  until  he  has  satisfied  him- 
self on  tltis  scon — the  surgeon  removes  the  limb, 
ligates  the  vessels,  and  when  all  oozing  has  ceased, 
secures  the  stump  by  points  of  suture  placed  at 
intervals  of  an  inch  or  a  little  less  along  the  entire 
line  of  wound. 

///  dividing  ih<-  skin,  //<<■  surgeon  cannot  be  t<«>  care- 
ful to  leave  <n<  ample  flap  i<>  cover  thi  /<<>"/>•  of  the 
hems.  This  is  the  tirst  and  most  important  rule 
in  amputation.     You  cannot  well  leave  too  much 

skill,  and  can  \>-v\  easily  commit  the  opposite 
error.  Tin-  surplus  of  skin  will  he  absorbed;  a 
deficiency  can  in  no  way  be  supplied.  The  rule 
is,  i"  have  the  flaps  bo  ample  that  no  tension  be 

:\V\    ill   closing  the  Wound.       due  of   the    | 


HOW    T<>    DEI 

constant  as  well  as  one  of  the  most  frightful 
exhibitions  in  the  military  hospitals,  whore  the 
Burgeons  have  not  yet  gained  experience,  is  the 
protrusion  of  the  bones  from  the  stamps  of  am- 
putated  limbs,  necessitating  .1  second  operation 
should  the  patient  survive  tin-  tir>t.  A  little  cure 
will  obviate  all  this  trouble,  and  save  the  >m. 
1 1 1  iuIi  mortification.  Any  omission  in  this  respect 
must  be  corrected  before  tin-  stump  is  dressed : 
:m<l  if  the  I". 11c  is  found  so  long  that  tin-  skin 
cannot  he  made  t«>  cover  it  without  traction,  re- 
move a  section  of  hone  with  the  saw,  and  not 
attempt,  through  want  of  honesty,  to  conceal  a 
badly-performed  operation,  and  make  the  inno- 
cent patient  the  victim  of  our  misplaced  pride. 
In  ligating  the  vessels,  tie  every  one  which  bleeds 

or   is  likely   to   hlced.       It    i-    not    derogatory    top   a 

surgeon  to  apply  ten.  fifteen,  or  even  twenty  liga- 
tures to  ;i  st  II 1 1 1 1  >  ;    it  .-hows  that   he  II  lldel'sl  amis  his 

profession;  experience  has  taught  him  the  . 

trouble    and    annoyance  of  reopening  a   -tump   to 
find  a  bleeding  vessel,  when  he  has  hut  little  time 

to  attend    to    the  urgent  demands  of  the  wounded. 

'J' In   ful,   is.  neglect  no  small  artery. 

adhesive  straps  for  supporting  ami  sustain- 
ing the  daps  are  antagonistic  to  water  dressings, 
they  are  Useless   in  amputations,  and  arc  not  used, 


HOW    TO    DBMS   STUMI's.  42!) 

except  a  small  patch  to  secure  the  ligatures  upon 
the  limb  at  one  angle  of  the  wound.  Sutures 
are  recommended  in  all  operations,  as  they 
keep  the  flaps  in  apposition — not  being  influ- 
enced by  the  water  dressings;  they  also  obviate 
much  after-dressing.  A  Bingle  layer  of  wet  cloth 
is  applied  to  the  stump;  this,  in  turn,  is  covered 
by  a  piece  of  waxed  cloth,  to  keep  in  the  moist- 
ure, and  either  an  ice  bladder  <>r  water  by  irriga- 
tion is  continuously  applied  over  this  outer  cloth. 
The  case  should  now  he  looked  upon  as  a  wound, 
and  should  he  treated  accordingly.  The  course 
laid  down  for  wounds  is  here  strictly  applicable, 

and   should  he  closely  followed. 

In  certain  cases  of  amputation,  as  in  the  cir- 
cular, where  the  skin  alone  forms  the  flap,  the 
dressing  may  he  changed,  as  follows:  After  ap- 
plying sutures  to  the  entire  Length  of  the  wound, 
draw  the  intervening  Bpaces  accurately  together 
by  means  of  strips  of  isinglass-plaster,  and  cover, 
also,  the  length  of  the  wound  with  a  folded  strip, 
only  leaving  uncovered  the  angle  where  the  lig- 
atures escape,  and  where  drainage  from  within 
i-  permitted.  The  object  of  the  dressing  is  to 
convert  the  wound  into  a  subcutaneous  one.  ex- 
oludiug  the  air  and  hastening  union.  To  the 
stump  no  other  dressing   i-  applied,  the  wound 


430  TREATMENT    AFTER    AMPUTATIONS. 

being  exposed.  No  water  dressing  is  to  be  used, 
and  Tin-  -lump  is  left  unmolested,  except  in 
cleansing  the  effects  of  drainage.  At  the  expi- 
ration <>f  a  week.  the  removal  of  the  Btraps 
will  show  complete  cicatrization  along  the  lino 
of  incision.  In  healthy  patients,  and  in  a  pnre 
atmosphere,  a  rapid  healing  of  stumps  may  in 
this  way  be  obtained.  The  isinglass-plaster  will 
alone  answer  fbr  this  dressing  —  the  diachylon 
being  too  irritating,  and  not  sufficiently  pliant  to 
eal,  hermetically,  the  wound.  We  find  but  lit- 
tle use  for  ointments  in  dressing  stumps,  the  wel 
•  •loth  being  much  simpler,  not  irritating,  and. 
therefore,  more  efficient. 

During  the  treatment  of  all  wounds  in  mili- 
tary hospitals,  previous  want  and  exposure,  which 
belongs  to  every  army,  however  well  organized; 
will  show  their  influence;  and  if  the  plan  of 
abstemious  or  antiphlogistic  diet  be  adopted  for 
those  operated  upon,  from  misguided  view 
the  pathology  of  inflammation,  the  mortality  will 
he  heavy.  Liberal  feeding  tells  in  the  . 
treatmenl  of  amputations;  and  the  great  differ- 
ence in  the  surgical  statistics  of  the  French  and 
English  depends  more,  perhaps,  upon  the  dirt  in 
their  hospital  practice  than  11)1011  any  one  other 
cause.      Tisanes    cannot    support    a   person   in   or- 


TREATMENT    AFTER    AMPUTATIONS.  431 

dihary  health,  and  certainly  cannot  support  him 
under  the  additional  drain  of  an  exhausting  sup- 
puration. Tf  patients  are  placed  under  identi- 
cally similar  conditions,  the  successful  treatment 
of  amputations  will  be  found  to  loan  to  the  side 
of  those  who  are  the  most  Kberally  supported. 
Slops  arc  out  of  place  in  a  surgical  hospital,  and 
li'ood  cooking  will  be  found  as  useful  as  good 
nursing.  Let  nature  be  our  guide.  For  the 
first  one  or  two  days  after  a  serious  operation, 
there  is  hut  little  disposition  to  eat.  Under  such 
conditions.  T  would  not  advise  food  to  he  forced; 
hut.  as  soon  as  the  patient  expresses  a  desire  to 
cat.  foster  his  appetite  with  good,  strong,  nour- 
ishing, easily-digested  food,  and  lei  his  supply 
he  liberal.  Any  attempt  at  starvation  will  be 
highly  injurious. 

If  the  patient  escapes  the  ordinary  diseases 
incident  to  hospitals,  viz:  erysipelas,  gangrene, 
pviemia.  etc..  we  must  he  extremely  careful  of 
him  about  the  tenth  or  twelfth  day.  When  the 
ligatures  arc  escaping  from  the  arteries,  absolute 
rest  should  he  insisted  upon,  and  the  patient 
should  not  be  allowed  to  exert  himself  in  any 
way  until   this   fear  of  secondary  hemorrhag 

d.     We  have  elsewhere  stated  how  this  com- 
plication is  to  be  met. 


432  OBLOftOJ^OBM. 

Whenever  operation!  arc  to  be  performed  in 
military  surgery,  chloroform  should  be  adminis- 
tered. It  is  a  remedy  which  the  surgeon  should 
never  be  without,  and  which  might  be  need  <m 
all  occasions  with  advantage,  whether  for  oper- 
ations or  for  dressing  painful  wounds,  as  in  the 
cleansing  of  compound  fractureS.  The  effects  of 
chloroform  are  wonderful  in  mitigating  the  Buf- 
fering of  the  wounded,  and  it  is  often  instru- 
mental in  the  cure  of  wounds,  from  the  Mai 
and  tranquility  of  mind  which  follows  its  inhala- 
tion. It  also  prevents  excessive  reaction  in  the 
paroxysms  of  traumatic  fever.  During  the  per- 
formance of  capital  operations  on  the  battle  field, 

death  sometimes  ensues  from  nervous  exhaus- 
tion, produced  by  excess  of  Buffering;  the  use 
of  chloroform   relieves   the   patient  at  least  from 

this   risk. 

Those  brought  up  in  the  older  school,  before 
the  davs  of  anaesthetics,  in  refusing  all  innova- 
tion-:, still  insist  on  decrying  the  dangers  of  this 
potenl     remedy,    and    moralize    upon     the    duty   of 

suffering,  as  submitting  to  an  express  infliction 
from    on   high.      Although  the    French  surgeons 

in  the  Italian  campaign  of  1859  report  the  suc- 
cessful    administration    of   chloroform    to    thirty 

thousand    wounded,    without    a    single    accident, 


CHLOROFORM.  483 

and  McLeod  refers  to  its  great  utility  in  the 
Crimea,  where  it  was  administered  to  twenty 
thousand  soldiers,  and  more  than  realised  the 
most  enthusiastic  anticipations  of  the  medical 
stall's,  still  we  find  some  of  the  older  school,  who 
are  in  authority,  sneer  at  its  pretensions  and 
magnify  its  dangers. 

Dr.  Hall,  who  is  at  the  head  of  the  English 
medical  staff,  in  giving  instructions  to  the  sur- 
geons upon  entering  active  service  in  the  Crimea, 
cautioned  them  against  the  administration  of 
chloroform  in  the  severe  shock  of  serious  gun- 
-hot  wounds,  as  he  thinks  that  few  will  survive 
where  it  is  used.  But,  as  he  finds  puhlic  opin- 
ion, which  he  calls  mistaken  philanthropy,  against 
him,  he  disparages  chloroform,  and  lauds  the 
lusty  bawling  of  the  wounded  from  the  smart 
of  the  knife,  as  a  powerful  stimulant  which  has 
roused  many  a  sinking  man  from  his  apathetic 
state.  Some  of  the  older  surgeons  characterize 
the  cries  oi  the  patient  as  music  to  the  ear,  and 
-peak  of  it  as  an  advantage  to  l»e  eourted,  and 
not  to  he  suppressed.  Notwithstanding  such 
advice,  the  universal  use  oi'  chloroform  in  the 
Crimea,  and  later  in  Italy,  is  a  complete  vindi- 
cation of  the  utility  of  the  remedy,  and  proof  of 
IK 


CHLOROFORM. 

its  necessity.  Now  we  consider  it  an  essential 
among  :trin\   >u|«|>! 

For  ourselves,  we  place  unlimited  confidence 
in  it-  judicious  administration,  a>.  with  :i  large 
experience,  we  have  never  had  the  slightest  cause 
t<>  douhl  it-  advantages  under  every,  circumstance. 
We  hope  thai  the  humanizing  tendencies  of  the 
aire,  in  introducing  this  invaluable  comfort,  has 
banished  that  dread  of  being  cut  as  an  item  to 
be  considered  when  operations  are  necessary  ;  and 
we  hope  to  see  anaesthetics  used  as  liberally  in 
allaying  the  pain  of  surgical  affections  a>  cold 
water  is  now  used  for  keeping  down  in  flam  ma- 
tiou.  Wi  do  not  hesitaU  to  say,  thai  it  should  be 
given  t"  every  patient  requiring  a  serious  or  painful 
operation.  We  may  hear  now  and  then  of  an 
accident   from    its   administration,   but    who   can 

tell  us  of  the  immense  nuinher  who  would  have 
sunk  from  operations,  had  it  not  been  admin- 
istered ''. 

In  its  administration,  we  must  USC  the  follow- 
ing precautions:  The  best  apparatus  is  a  folded 
cloth,  in  the  form  of  a  cone,  in  the  apex  of  which 
a  Bmall  piece  of  sponge  is  placed.  This  is  first 
held  at  some  distance  from  the  uose  and  month 
of  the  patient.  10  that  the  fust  inhalation  may 
be    well    diluted   with  air.       A.-    the    exhilarating 


CHLOROFORM.  435 

stage  is  readied,  the  cloth  should  be  approached 
to  the  nose,  so  that  a  more  concentrated  ether 
inny  ho  inhaled,  which  will  rapidly  produce  the 
desired  insensibility.  Noisy  breathing  is  tin'  sign 
that  the  anaesthetic  effect  is  produced,  when  the 
inhalation  should  he  suspended,  and  the  opera* 
tion  commenced.  Unless  the  operation  is  very 
tedious,  do  not  renew  the  inhalation. 

Ingenious  inhalors  are  mere  or  loss  compli- 
cated, and  are.  on  that  account,  more  or  less 
inefficient.  The  great  perfection  of  the  above* 
mentioned  apparatus  is  its  simplicity*  Finding 
that  much  chloroform  is  wasted  by  evaporation 
from  the  handkerchief,  1  have  for  some  years 
usod  a  common  funnel  as  my  inhaler,  which  pro- 
tects the  hands  of  the  person  administering  the 
chloroform,  and  prevents  the  loss  from  general 
evaporation.  If  a  piece  of  heavy  wire,  or  a  small 
har  of  tin.  he  attached  across  the  interior  of  the 
funnel,  about  half-way  toward  its  throat,  the 
sponge  containing  the  chloroform  can  be  sup- 
ported between  this  har  and  the  side  of  the 
funnel,  leaving  a  space  on  one  side  for  the  air 
to  rush  over  the  surface  of  the  sponge  as  it 
comes  through  the  elongated  end  of  the  appara- 
tus, when  the  air.  loaded  with  ether,  is  inhaled. 
The  funnel  should  he  large  enough  to  cover  the 


I  ■lll.dlliiFollM. 

tower  half  of  the  face,  including  the  nose  and 
mouth,  and  the  sponge  Bhould  nol  come  within 
two  inches  of  the  face,  for  Bhould   it  touch  the 

skin  it  would  blister  it.  The  eyes,  being  exclud- 
ed from  the  apparatus,  are  not  annoyed  by  the 
evaporation  of  chloroform.  A.s  the  funnel  does 
not  in  accurately  to  the  lower  outline  of  the 
face,  there  will  be  ample  spaces  on  either  side 
of  the  chin  to  admit  air  for  diluting  the  vapor. 
Besides  a  great  saving  of  chloroform,  which  is 
no  small  recommendation,  the  use  of  this  instru- 
ment obviates  the  tear  of  suffocation,  which  is 
always  present  to  my  mind  when  I  see  chloro- 
form carelessly  administered.  When  the  cloth  is 
used,  should  the  patient  struggle — ■  very  com- 
mon occurrence  —  or  should  the  assistant  admin- 
istering the  anaesthetic  be  at  all  interested  in 
the  operation,  the  cloth  is  thrust  down  upon  the 
face  of  the  patient,  respiration  is  impeded,  and 
suffocation    is    imminent.      Suppose    the    patient 

lias    already    heen    influenced    to    such    an    extent 

that  he  has  l<»st  the  voluntary  control  of  his 
muscles,  and  cannot  pull  away  the  cloth,  he  is 
in  a  very  dangerous  condition,  and  the  continued 
thoughtlessness  of  the   assistant    might    suffocate 

Hjm.      I    can    readily   understand,  in   this  way.  why 

deaths   should    sometimes  occur   from    the    care- 


CHLOR0F0BM  437 

lessncss  of  administration,  and  am  only  surprised 
that  it  occurs  so  seldom.  Were  we  as  careless 
in  the  use  of  other  potent  remedies  as  we  arc  of 
chloroform,  cases  of  poisoning  would  be  largely 
increased.  In  times  of  hurry,  contusion  and  ex- 
citement, as  after  a  battle,  we  cannot  surround 
the  safety  and  well-being  of  the  wounded  with 
too  many  guards  for  their  protection. 


MALIK G  KlJlXn 


In  closing  this  Manual,  experience  induce-  me 
Id  oflfef  to  army  BiiT^eona  a  few  suggestions  re- 
garding the  frauds  daily  practised  upon  Medi- 
cal officers  by  impostors,  who  feign  disease  i" 
escape  military  duly.  Malingering,  or  the  feign- 
ing of  disease,  lias  ever  been  and  will  continue 
to  be  popular  with  soldiers,  irrespective  of  the 
materia]  of  which  the  army  is  composed.  Hon- 
esty "i'  purpose  and  patriotic  motives  ate  net, 
the  only  incentives  i<»  enlistment,  even  against 
such  an  invasion  as  our  enemies  are  now  carry- 
ing <>n  for  the  destruction  of  all  our  most  sacred 
and  cherished   rights. 

The  odium  heaped  upon  those  who  would  re- 
main at  home,  lias  forced  many  into  the  ranks 
who  were  hut  little  disposed  to  give  up  their 
comforts  and  their  habitual  idleness  for  the 
active  and  laborious  duties  of  camp  life.  Such 
soldiers  are  always  ready  to  use  every  subter- 
fuge tor  escaping  from  what  is  irksome  ami  dis- 
tasteful t,.  them:  and  as  complaints  of  indisposi- 
tion oiler  an  easy  release,   it    is  the  plan  usually 


MALINGEKIXO.  I-'.1 

adopted.  Moreover,  where  large  bounties  are 
offered  for  enlistment,  many  are  found  who 
would  enlist,  obtain  the  bounty  and  a  suit  of 
clothes,  and,  by  feigning  disease,  successfully  im- 
pose upon  their  medical  officers,  be  discharged 
from  service,  to  re-enlist  in  a  few  days.  In- 
stances are  known  in  which  this  course  has  been 
successfully  pursued  several  times  in  a  short 
period.  Hence  it  is  that  the  study  of  feigned 
diseases  heroines  an  important  branch  of  mili- 
tary surgery,  both  for  the  protection  of  the  ser- 
vice and  the  detection  i){  fraud.  Unless  medical 
officers  are  aware  of  impostors,  and  are  always 
on  the  alert  to  detect  and  punish  such  imposi- 
tions, the  service  gutters  seriously,  and  the  will- 
ing soldier  is  over-taxed  with  double  duty. 
—  Among  the  varieties  of  sickness  classified  as 
malingering,  are  slight  indispositions,  much  ex- 
aggerated; or  the  symptoms  of  disease  may  be 
purely  fictitious,  whilst  diseased  conditions,  such 
as  ophthalmias,  a  leers,  wounds,  etc,  etc.,  may  be 
either  intentionally  produced  or  aggravated  by 
the  malingerer. 

General   experience  shows   that,   at  times,  one 

may   feel    more   or  Less  depressed,   with   uneasy, 

ous  feelings,  foreboding  sickness.     These  are 

transienl    conditions,    depending,    perhaps,    upon 


a  disturbed  digestion,  aud  will  disappear  spon- 
taneously ai  the  t'lnl  of  ■  few  hours,  leaving  us 
in  pur  accustomed  health,  Ignorant  or  infatu- 
ated is  that  physician  who  believes  medicine 
necessary  for  every  such  temporary  indisposition, 
and  who  adopts  the  rule  of  prescribing  drugs 
for  every  person  who  presents  himself  for  treat- 
ment. This  coustanl  drugging  is  detrimental 
to  the  service,  in  making  cases,  and  diminish- 
ing the  effective  strength  of  a  command,  whilst 
it  squanders  medicines  which  arc  only  replaced 
with  trouble  and  expense.  A  little  moral  cour- 
"U  the  part  of  the  medical  officer  t<>  refuse 
the  applicant  as  a  patient,  and  a  word  to  the 
commanding  officer,  to  overlook  his  call  for 
guard  duty,  will  gain  him  the  confidence  and 
the  respect  of  the  soldier-  The  surgeon  should 
not  aet  hastily  in  his  diagnosis,  hut  should  pa>s 
judgment  only  after  a  careful  study  of  the  ease: 
for  it  is  hard  to  force  a  sick  man  to  duty,  hut 
feigned  diseases,  which  escape  detection,  ate  re- 
wards granted   to   fraud. 

Among  the  diseases  most  readily  and  frequent- 
ly feigned,  are  pain,  rheumatism,  deafness,  Im- 
paired vision,  etc.;  all  of  these  are  as  difficult  of 
detection  as  their  simulation  is  easy,  ami  hence 
the    readiness   with    which    such    complaints   are 


MAfilNOBftlNG.  411 

feigned.  When  we  arc  called  upon  to  investigate 
these  suspected  cases,  we  must  carefully  weigh 
the  moral  and  physical  condition  of  the  patient — 
liis  habits,  his  probable  motives,  with  the  pres- 
ence or  absence  of  pathognomonic  symptoms. 
During  the  examination  we  must  mark  the  dispo- 
sition of  such  malingerers  to  overact  their  part, 
their  anxiety  to  impress  us  with  the  reality  and 
severity  of  their  sufferings,  and  also  the  readiness 
with  whieh  they  can  lie  led  on  to  acknowledge 
the  presence  of  incompatible  and  preposterous 
symptoms. 

When  pain  is  feigned,  as  this  may  really  exist 
as  a  disease  without  external  manifestation,  it  is 
the  most  difficult  of  all  symptoms  to  detect.  By 
close  observation  and  constant  watching  the  fraud 
may  he  detected,  although  the  malingerer  may 
continue  his  complaints  until  he  attains  his  ob- 
ject— a  discharge  from  the  service.  In  studying 
out  this  imposition,  we  must  examine  info  the 
nature  and  cause  of  this  pain — its  duration  and 
intensity — iis  character,  whether  fixed  or  wan- 
dering, whether  persistent,  remitting,  or  inter- 
mitting, and  whether  increased  or  diminished  by 
pressure:  for  no  pari  can  be  exquisitely  sensitive 
under  pr<  ssure,  which  will  not  show  other  indi- 
cations   of   local    trouble.      If   the    patient    com- 


442  MAMNCKUlNt, 

plains  of  an  internal  pain,  we  Bhould  examine 
whether  it  be  accompanied  by  those  Bymptome 
which  it  is  impossible  to  :i — iiiii*-.  and  the  absence 
of  which  would  lead  to  suspicion. 

Much  may  also  be  learnt  from  the  treatment 
pursued.  In  real  diseases,  painful  remedies  will 
not  be  objected  to,  whilst  in  the  feigned  a  decided 
aversion  is  shown  when  the  use  of  these  remedies 
is  threatened.  1  have  cured  a  pain  of  six  months 
standing  in  a  malingerer  by  the  use  of  the  actual 
cautery,  and  the  promise  that,  if  the  first  applica- 
tion did  not  remove  all  the  pain,  a  second  would 

most    certainly   effect    it.      Kven    the    prospect   of  a 

severe  application  on  the  following  day.  if  the 
patient  does  not  feel  better,  lias  brought  its  fruit. 
rI  'his,  however,  does  not  always  succeed,  as  malin- 
gerers have  withstood  the  repeated  application 
of  the  most  powerful  remedies,  and  have  >'^\\- 
U'^r^cd  their  imposition  only  after  exhausting  the 
resources  of  the  snspectiug  surgeon,  or  after 
obtaining  their  dismissal;  A  simple  mode  of 
testing  the  sensitiveness  of  what  tin'  patient 
complains  of  as  an  intense  pain,  is  by  niaking 
pressure    upon    the   part    when    the    patient    sleeps. 

sleep,  in  itself,  may  lead  to  detection,  as  quiet, 
placid  Bleep  at  night,  with  intense  pain  during 
the  day.  without   los<  of  flesh  or  general  impair- 


mai,in<!Ki:in<;.  443 

merit  of  the  digestive  orpins,  are  a  combination 
which   belongs  io  no  known   disease. 

The  pains  complained  of  by  malingerers  usu- 
ally assume  the  form  of  a  rheumatism,  which 
withstands  all  treatment.  Notwithstanding  the 
liberal  use  of  remedies,  this  pain  continues  un- 
mitigated—  the  patient  at  all  times  suffering  se- 
verely; whilst  the  true  disease  is  mostly  affected 
by  changes  in  the  weather.  Catechising  in  the 
feigned  disease  will  readily  mislead  the  patient 
into  acknowledging  inconsistent  and  contradic- 
tory symptoms,  which,  in  many  cmm's.  will  lead 
to  detection.  Intense  and  long  continued  pain 
in  a  joint  cannot  exist  as  an  isolated  symptom. 
Walking  with  a  stick,  which  patients  think  ne- 
cessary  to  influence  the  medical  officer,  is  an  ex- 
pedient common  to  all  those  whose  indispositions 
are  less  serious  than  they  would  have  the  medi- 
cal  officer  believe. 

A  feigned  paralysis  of  the  arm  —  a  disease  at 
times  assumed — can  he  readily  detected  during 
sleep,  by  tying  the  sound  arm  to  the  body  and 
tickling  the  nose  or  lips,  when  the  palsied  arm 
will  innocently  move  to  the  face  to  brush  away 
the  offending  body. 

Deafness   comes    next    in    order   as   a   disease 
difficult    of  detection,    and.    therefore,    frequently 


Ill  MALINGERING 

assumed.  Those  familiar  with  this  disease  will 
often  notice  a  peculiar  manner,  which  he! 
to  auch  only  a>  have  difficulty  in  hearing.  The 
oon  must  exercise  his  ingenuity  in  devising 
means  for  exposing  the  imposition.  A.mong 
would  he  making,  suddenly,  loud  noiseo, 
such  as  discharging  a  pistol  near  the  ear  of  the 
unsuspecting  person.  Very  few  have  such  eon* 
trol  <»\cr  themselves  as  to  withstand  this  trial, 
although  instance-  are  known  where  impostors 
remained  unmoved,  notwithstanding  this  tout 
Relating  a  conversation  in  which  tin-  patient  is 
deeply  interested,  ami  watching  clandestinely  the 
play  »>f  liis  features,  will,  at  times,  lead  t<>  de- 
tection. 

Like  impairment  in  hearing,  so  is  impaired 
Bight  a  very  common  complaint  among  those 
who  desire  to  escape  duly.  Night  or  day  blind- 
ness i^  a  complaint  which  may  have  foundation 
under  oertain  circumstances,  Inn  i-  rarely  met 
with.  When  suspicion  is  aroused,  compulsory 
duty  is  the  best  remedy.  Under  the  plea  that, 
for  sentinel  duly,  ami  especially  lor  night  duty, 
hearing   is   even    more   important    than 

and    as    four    fars    arc    always    loiter   than    two.   a 

double  guard,  of  which   the    malingerer   is   one, 
should    he    placed    at    the    post.      At    the    same 


MALrNOERINO. 


445 


time,  a  low  diet  will  show  the  impostor  that 
his  complaint  does  not  moot  with  much  sym- 
pathy. A  soldier  may  appear  before  the  medi- 
cal officer  with  an  excessively  dilated  pupil,  and 
with  a  complaint  of  impaired  vision.  It  must 
ho  remembered  that,  as  a  disease,  this  symptom 
seldein  appears  alone,  and  that  a  drop  of  a  solu- 
tion of  belladonna  will  at  any  time  induce  it. 
Where  such  a  ease  excites  suspicion,  searching 
the  patient  and  locking  him  up,  under  guard, 
will  in  a  few  days  solve  the  douhts  by  the  re- 
turn of  the    pupil   to  its  normal   dimensions. 

Epilepsy  is  another  disease  often  attempted. 
To  have  fits  is  thought  by  the  public  to  be  the 
acme  of  an  incurable  condition,  deserving  the 
commisseration  of  a  community,  and  the  soldier 
necessarily  infers  that  a  man  who  can  have  a 
tit  whilst  in  camp,  surrounded  by  his  compan- 
ions, may  have  a  similar  one  whilst  on  guard 
duty,  and  is.  therefore,  not  a  proper  person  to 
he  entrusted  with  the  protection  of  a  camp.  This 
disease  has  been  so  frequently  feigned,  both  in 
civil  as  well  as  military  life,  and  the  symptoms 
Of    the     disease     have     been     so     carefully     studied. 

that  ni<»st  surgeons  will  he  en  their  guard  against 

such   impostors.      A    dTOp   of  turpentine  or  alcohol 
in    ii.  U4  li    an    one   will,    without    d 


44ti  MALINGERING. 

harm,  bring  his  acting  to  a  speedy  close.  Vety 
few  impostors  can  stand  tliis  innoceut  test.  It 
is,  perhaps,  as  well  to  state  thai  during  the 
epileptic  lit  all  insensibility  is  for  the  time  sus- 
pended. 

A  feverish  skin  may  also  be  simulated  by  the 
liberal  use  of  a  ftesh  brush,  whilst  the  foulest  '-"at 
upon  the  tongue  can  he  manufactured  at  will  by 
a  local  application  of  chalk,  day,  ashes,  brick- 
dust,  Hon)-,  soap,  etc.  Deformities  and  contrac- 
tions of  the  limbs,  which  are  never  drawn  up 
during  sleep,  or  under  the  influence  of  chloro- 
form, arc  also  feigned  l>y  malingerers,  and  will 
require  the  most  careful  scrutiny.  In  order  i>> 
deceive,  the  mouth  is  scarified  to  permit  the  spit- 
ting of  blood,  ulcerations  on  the  legs  are  made 
by  the  pressure  of  hard  substances,  and  swollen 
arms  and  legs  by  ligating  the  extremities  near 
the  trunk.  Frequent  micturition  or  diarrh.ea  may 
easily  be  complained  of,  and  dysenteric  stools 
have  been  actually  stolen  from  neighboring  pa- 
tients to  assist  in  carrying  out  the  deception. 
It  is  only  necessary  for  surgeons  to  know  to 
what  extent  diseases  may  he  feigned,  to  be  pre- 
pared to  meet  the  impostors.;  and  by  using  all 
the  means,  both  morally  and  medically,  which 
their  ingenuity/  would  suggest,  to  detect  and 
punish  the  malingerer. 


APPENDIX. 


Appendix  No.  1. 


REGULATIONS 

FOR 

THE   MEDICAL    DEPARTMENT 

OF    TIIK 

CONFEDERATE  STATES. 


1160.  .The  Surgeon-General  is  charged  with  the  administra- 
tive details  of  the  medical  department,  the  government,  of  hos- 
pitals, the  regulation  of  the  duties  of  surgeons  and  assistant 
surgeons,  and  the  appointment  of  acting  medical  officers,  when 
needed,  for  local  or  detached  service.  He  will  issue  orders 
and  instructions  relating  to  the  professional  duties  of  medical 
officers;  and  all  communications  from  ^theni,  which  require  his 
action,   will   be    made   directly  to  him. 

1151.. The  Medical  Director  of  an  army  corps  will  have 
the  general   control   of  the  medical   officers. 

1152.  .The  Medical  Director  will  inspect  the  hospitals  under 
bis  control,  and  see  that  the  rules  and  regulations  with  regard 

to  them    and   the   duties  of  the   surgeons  and   assistant  surgeons 

arc  enforced. 

1153. .He  will   examine    the   case   books,   prescription    and 

diet     hooks,    and    ascertain     the    nature    of   disease's    which    may 

hare  prevailed,  and  their  probable  causes:  recommend  the  best 
method  of    prevention,   and   also  make    such  Aiggestionfl  rela- 


4f>')  APPENDIX. 

tivo  to  the  -it 'in inn.  construction  and  economy  of  the  hospi- 
tals, and  to  the  police  of  the  camps,  as  may  appear  ne  ■ 
for  the  benefit  and  comfort  of  the  sick,  and  the  good  of  the 
sen  i 

1154.  .From  the  monthly  reports  of  the  m« -< Ti< -nl  offici 

the  command  (Form  1),  he  will  make  to  the  Surgeon-General 
a  consolidated  monthly  report  of  the  sick  and  wounded. 

1155.  .He  will  make  t<>  the  Surgeon-General  a  monthly  re- 
turn (Form  •-' )  of  the  medical  officers  of  the  command. 

1156.. The  Medical  Purveyor  will,  under  the  direction  of 
the  Surgeon-General,  purchase  all  medical  and  hospital  supplies 
required  tin-  the  medical  department  <>t'  tin-  army. 

1157.  .Medical  Purveyors  will  make  to  the  Surgeon-General, 
at  the  end  dt'  eacjh  fiscal  quarter,  returns  in  duplicate  (Form  •'> ) 
of  medical  supplies  received,  issued,  ami  remaining  on  hand — 
stating  to  whom,  or  from  whom,  ami  when  ami  where  issued  or 
received.  Other  medical*officers  in  charge  of  medical  supplies 
trill  make  similar  returns  semi-annually,  on  the  SOth  of  June 
and  the  SI  si  of  December;  ami  all  medical  officers  "ill  make 
tin  in  when  relieved  from  tin-  dutv  to  which  their  returns  relate. 
The  returns  will  show  the  condition  of  the  stores,  and  particu- 
larly of  the  instruments,  bedding  and  furniture.  Medical  pur- 
veyors "ill  furnish  abstracts  of  receipts  and  issues,  with  their 
returns  (  Form  4). 

LI 58.  .Medical  disbursing  officers  will,  at  the  end  of  one* 
tic.il  quarter,  render  to  the  Surgeon-General,  in  duplicate,  a 
quarterly  account  currtfil  of  moneys  received  and  expended, 
with  tin-  proper  vouchers  for  the  payments,  and  certificates  that 
the  scr\iei-<  have  been  rendered  and  the  supplies  purchased  and 
received  for  the  median!  service,  and  transmit  to  him  an  esti- 
of  the  funds  required  for  the  m-xt  quarter. 

1159.  .The  medical  supplies  for  the  arm}   are  prescribed  in 

the  Standard    Supply  Tali]cs*for    Hospitals  and   Field   Service. 

i  n;o.  .Medical  and  hospital  supplies  will  be  obtained  by  mak- 
ing requisitions,  in  duplicate  ( Form  5),  on  the  Surgeon-General, 
forwarding  them  through  the  Medical  Director  of  the  command. 

If  an  army  he  in  the  Held,  aifd  there  he  a  Medical  Purveyor  in 
charge  of  supplies,  requisitions  will  he  made  on  him.  after  receiv- 


APPENDIX.  4"'l 

inp  the  approval  of  the  Medical  Director.  The  quantities  on 
hand,  of  the  articles  wanted,  must  be  stated  in  all  requisitions. 
L161..When  it  is  necessary  to  purchase  medical  supplies, 
those  which  are  indispensable  may  be  procured  by  the  quar- 
termaster, if  recourse  cannot  be  had  to  a  medical  disburs- 
ing officer,  on  a  special    requisition   (Form   6),  and   account 

(  Form  7). 

m>2.  .In  every  case  of  special  requisition,  a  duplicate  of  the 
requisition  shall,  at  the  same  time.  In'  transmitted  to  the  Surgeon- 
(ieneral  tor  his  inl'ormation. 

il<).»..  An   officer  transferring  medical  Bupplies  will  furnish 

a  certified  invoice  to  the  officer  who  is  to  receive  them,  and 
transmit  a  duplicate  of  it  to  the  Surgeon-General.  The  receiv- 
ing officer  will  transmit  duplicate  receipts  (specifying  an  ides 
and  quantities)  to  the  Surgeon-General,  with  a  report  of  the 
quality  and  condition  of  the  supplies,  and  report  the  same  to 
the  issuing  officer.  A  medical  officer  who  turns  over  medical 
supplies  to  a  Quartermaster  tin-  storage  or  transportation,  will 
forward  to  the  Surgeon-General,  with  the  invoice,  the  Quarter- 
master's receipts  for  the  packages. 

IL64.  .Medical  officers  will  take  up  and  account  tor  all  medi- 
cal   supplies   of-  the    army    that    come    into  their    possession,   and 

report,  when  they  know  it.  to  whose  account  they  are  to  be 
credited. 

1165.  .Medical  supplies  are  not  to  he  detained  or  diverted 
from  their  destination,  except  in  cases  of  absolute  necessity,  by 
commanding  Generals,  who  will  promptly  report  the  circum- 
stances to  the  Adjutant-General,  that  orders  ma}  he  given  tor 
supplying  the  deficiency;  and  the  medical  officer  receiving  them 
will  immediately  report  the  tact  to  the  Surgeon-General;  and, 
ako,  when  practicable,  notify  the  officer  tin'  whom  they  were 
intended. 

inn;.  .In  all  official  lists  of  medical  supplies,  (he  articles  will 

he  entered  in  the  order  of  the  supply  tables. 

1167.  .The  senior  medical  officer  of  each  post,  regiment,  or 
detachment,  will,  with  the  approbation  of  the  commanding 
officer,  select  a  suitable  site  for  the  erection  of  a  hospital,  or  of 
hospital  tents. 


-!.">_'  AI'l'KM'IX. 

1168.  .'I'h''  senior  medical  officer  of  a  hospital  will  distribute 
the  patients,  according  t<>  convenience  ami  the  nature  of  their 
complaint*,  into  wards  or  divisions,  nnder  the  particular  charge 
of  tlif  several  assistant  surgeons,  and  will  \i-it  then  himself 
each  <lav  a<  frequently  as  the  state  of  the  Bick  ma)  require, 
accompanied  by  the  assistant,  steward,  and  nurse. 

1 1  69..  Ili-  prescriptions  of  medicine  and  diet  are  to  be  writ- 
ten down  at  once  in  the  proper  l»»>k.  with  the  name  <>t'  the 
patient  and  the  number  of  has  bed  ;  the  assistants  will  till  np  the 
diet  table  for  the  day,  and  direct  the  administration  of  the  pre- 
scribed medicinea  He  will  detail  an  assistant  Burgeon  to  re- 
main at  the  hospital  day  and  night,  when  the  state  of  the  >\<  k 
requires  it. 

ii7o.  .In  distributing  the  duties  of  his  assistants,  he  will  or- 
dinarily require  the  aid  of  one  in  the  oare  and  preparation  of  the 
hospital  reports,  registers  and  records,  the  rolls  and  descriptive 
bats;  and  of  another,  in  the  charge  of  the  dispensary,  instru- 
ments, medicines,  hospital  expenditures,  and  the  preparation  of 
the  requisitions  and  annual  returns. 

1171.. He  will  enforce  the  proper  hospital  regulations  to 
promote  health  and  prevent  contagion,  by  ventilated  and  not 
crowded  rooms,  scrupulous  cleanliness,  frequent  changes  of  bad- 
ding  .and  linen,  occasional  refilling  of  the  bed  Backs  and  pillow 
ticks  with  fresh  straw,  regularity  in  meals,  attention  to  cook- 
ing, etc. 

1172.  .He  will  cause  to  be  printed,  or  written  in  ;i  legible 
hand,  and  bung  up  in  a  conspicuous  place  in  each  ward,  such 
rules  and  regulations  as  he  ma]  deem  necessary  for  tin-  guidance 
ol  the  attendants,  and  the  order, cleanliness,  and  convenience  of 
the  patients. 

u::;..IIc  will  require  the  steward  to  take  due  care  of  the 
hospital  Btores  and  supplies;  to  enter  in  a  book,  daily  (Form 
s).  the  issues  to  the  wardmasters,  cooks  and  nurses;  to  prepare 
the  provision  returns,  and  receive  and  distribute  the  rations. 

1171.. He  will  require  the  wardmaster  to  take  charge  of  the 
effects  of  the  patients;  to  register  them  in  a  book  (Form  9);  to 

luive  them  numbered,  and  labeled   with  the  patient's  name,  rank 

and  company  ;  to  receive  from  the  Bteward  the  furniture-,  bed- 


AJ'l'ilMUX.  45o 

ding,  coding  utensils,  etc.,  for  use.  and  keep  a  record  of  them 
(  Form  10),  and  how  distributed  to  the  wards  and  kitchens,  and. 
oni'c  a  week,  to  lake  an  inventory  of  the  articles  in  use,  and 

report  to  him  any  loss  or  damage  to  them,  and  to  return  to  the 
steward  such  as  are  UOl  required  for  use. 

1175.  .Assistant  Surgeons  will  obey  the  orders  of 'their  senior 
Surgeon,  see  that  subordinate  officers  do  their  duty,  and  aid  in 
enforcing  the  regulations  of  the  hospital. 

1176.  .The  cooks  and  nurses  are  under  the  orders  of  the 
steward.  He  is  responsible  for  the  cleanliness  of  the  wards  and 
kitchens,  patients  and  attendants,  ami  all  articles  in  use.  He 
will  ascertain  who  are  present  at  sunrise  and  sunset,  and  tattoo. 
ami  report  absentees. 

1177.  .At  surgeon's  call  tin'  sick  then  in  the  companies  will  he 
conducted  to  the  hospital  by  the  first  sergeants,  who  will  each 

hand  to  the  Surgeon,  in  hi-  company  hook,  a  list  of  all  tin'  sick 
ot  the  company,  on  which  the  surgeon  shall  state  who  are  to  re- 
main or  go  into  the  hospital;   who  are   to  return  to  quarters  as 

-iek  or  convalescent ;  what  duties  the  convalescents  in  quarters 

are  capable  of;  what  cases  are  feigned;  and  any  other  informa- 
tion in  regard  to  the  sick  of  the  company  he  may  have  to  eom- 
munieate  to  the  company  commander. 

LI 78.  .Soldiers  in  hospital,  patients  or  attendant-,  excepl 
stewards,  shall  he  mustered  on  the  rolls  of  their  company,  it'  it 

he  present  at  the  post 

117:t.  ,  When  a  soldier  in  hospital  is  detached  from  his  com 
pam  so  as  not  to  In-  mustered  with  it  tin-  pay.  his  company  com- 
mander -hall  certify  and  semi  to  the  hospital  hi-  descriptive  li-t. 
and  account  ot  pay  and  clothing,  containing  all  necessary  infor- 
mation relating  to  his  accounts  with  the  Confederate  States,  on 
which  the  Surgeon  shall  enter  all  payments,  stoppage^  and 
i-ie ■-  of  clothing  to  him  in  hospital  When  he  leaves  the  hos- 
pital, the  medical  officer  shall  certify  and  remit  his  descriptive 
li-t.  showing  the  state  of  hi-  accounts.     It  he  is  discharged  from 

the  service  in  hospital,  the  surgeon  shall  make  mil  hi- final  statc- 

menta  tin-  pay  and  clothing.  It  he  die-  in  hospital,  the  surgeon 
-hall  take  charge  of  hi-  effects,  and  make  the  reports  required 


I    4  \ITK.\1H\ 

iii  the  peaeral  regulations  concerning  soldiers  who  die  aWut 
in. in  their  companies. 

1 180.  .  Patients  in  hospital  are,  it'  possible,  to  leave  their  anus 
■  ii. "1  accoutrements  with  their  companies,  and  in  no  case  i"  take 
ammunition  into  the  hospital 

1181. .When  i  patient  i>  transferred  from  one  hospital  i>> 
another,  I  he  medical  officer  .-hall  send  with  him  an  account  of 
hi-  case,  and  the  treatment. 

1182.  .The  regulations  for  the  service  of  hospitals  apply,  as 
far  as  practicable,  t<>  the  medical  service  in  the  field. 

1188. .In  the  field,  the  -i -i i it n-  medical  officer  will  inspect 
camps,  and  urge  the  enforcement  of  stringent  rules  of  police. 

1184.  .The  senior  medical  officer  of  each  hospital,  post,  regi» 
meat  or  detachment,  will  keep  the  follow  ing  records,  and  deliver 
theni  to  his  successor :  A  register  of  patients  (Form  il):  a  pre- 
scription  ami  dirt  book  (Form  12);  a  case  l>o<>k  :  copies  of 
i.i-  requisitions,  returns  of  property,  and   reports  of  sick  and 

wounded,  and  an  order  and  Inter  lunik,  ill  which  will  lie  tran- 
scribed all  orders  and  letters  relating  to  hi-  dutiea 

1185.  lie  will  make  the  muster  and  paj  rolls  of  the  hospital 
steward  and  laundresses,  and  of  all  soldiers  in  hospital,  sick  or 
on  duty,  detached  from  their  companies,  on  the  forms  furnished 
from  tin-  Adjutant  and  inspector-General's  oilier,  and  according 
to  the  directions  expressed  on  them. 

1186.  .The  extra  pay  allowed  to  soldiers  acting  as  cooks  and 
Durees  in  hospitals  will  lie  paid  bj  the  Quartermaster  Depart- 
ment —  the  extra  service  being  noted  QB  the  hospital  innsler  rolls. 

1  lis?.  .The  senior  medical  officer  will  select  the  cooks,  nurses, 
and  laundresses,  with  the  approval  of  the  commanding  officer. 
Cooks  ami  nurse-,  taken  from  the  privates,  will  be  exempt  from 

other  duty,  I'Ut  shall  attend  llie  parades  for  muster  and  weekly 
inspection  of  their  companies  at  the  post,  unless  specially  ex- 
cused l>\  the  commanding  officer.  They  will  not  In-  removed 
excepl  tor  misdemeanor,  ami  at  the  request  of  the  medical  offi- 
cer,  mil'-    in    cases  of  Urgent    necessity,   ami   then   only    by   the 

order  ot  the  commanding  officer. 

1188.  .Cooks  ami  nurses,  other  than  enlisted  man  or  volun- 
teers, an-  subject  to  military  control.      Tiny  will  lie  paid  on  the 


APPENDIX.  455 

hospital  muster  rolls,  by  the  Quartermaster  Department,  at  the 
rates  at  which  they  have  been  engaged,  which,  in  do  case,  will 
exceed  $18  50  per  month,  being  the  pay  proper  of  an  enlisted 
man.  together  with  the  extra  pay  allowed  in  paragraph  lf86. 
They  should  not  be  employed  for  a  less  period  than  a  calendar 
month. 

I  [89.  .Ordinarily,  hospital  attendants  are  allowed  as  follows  : 
To  a  genera]  hospital,  one  steward,  one  nurse  as  wardmaster, 
one  nurse  to  ten  patients,  one  laundress  to  twenty,  and  one  cook 
to  thirty;  to  a  hospital  where  the  command  exceeds  live  compa- 
nies, one  steward  ami  wardmaster.  one  cook,  two  laundresses 
and  four  nurses:  to  a  posl  or  garrison  of  one  company,  one 
steward  and  wanlmaster.  one  nurse,  one  cook,  and  one  laun- 
dress; ami  for  every  two  companies  more, one  nurse;  at  arsenals, 
where  the  number  of  enlisted  men  is  not  less  than  fourteen,  one 
laundress  is  allowed.  The  allowance  of  hospital  attendants  in 
the  field  will  he.  for  command-  of  one  company  and  not  exceed- 
ing five,  one  steward,  one  cook.  and.  lor  each  company,  one 
nurse  ;  for  regiments,  or  other  commands  of  over  five  companies, 
one  steward,  two  cooks,  and.  tor  each  company,  one  nurse. 

1  190.  .Medical  oliicers.  where  on  duty,  will  attend  the  officers 
and  enlisted  men.  and  the  laundresses  authorized  by  law:  ami 
at  stations  where  other  medical  attendance  cannot  lie  procured, 
and  on  marches,  the  hired  men  of  the  army.  Medicines  will  lie 
dispensed  to  the  families  of  officers  and  soldiers,  and  to  all  per- 
sons entitled  to  medical  attendance:  hospital  stores  to  enlisted 
men. 

1 191  .  .Medical  oliicers,  in  giving  certificates  of  disability 
(Form  18),  are  to  take  particular  care  in  all  cases  that  have  not 
bees  under  their  charvv  :  and.  especially,  in  epilepsy,  convul- 
sion-, chronic  rheumatism,  derangement  of  the  urinary  organs 
ophthalmia,  ulcer-,  or  any  obscure  disease,  liable  to  be  feigned 
or  purposely  produced:  and  in  no  caw  shall  such  certificate  be 

given  until  after  Btffficienl  time  and  examination  to  detect  an\ 
atti  nipt  at  deception. 

1192.  .In  passing  a  recruit,  the  medical  officer  is  to  examine 
him   stripped;   to  see  that  he   has  free  use  of  his  liml i>  :   that    his 

<hi  -t  i-  ample:  that  hi-  hearing,  vi-imi  ;;nd  speech  are  perfect; 


IV.  APPENDIX. 

that  he  has  no  tumors,  or  ulcerated  or  extensively  cicatrized 
no  rapture  or  chronic  cutaneous  affection ;  that  be  baa  not 
received  any  contusion,  i>r  (round  of  the  head,  th.it  may  impair 
hi?  faculties;  thai  he  is  not  ;i  drunkard;  is  not  subject  to  con- 
vulsions, and  has  no  infectious  disorder,  n«>r  any  <>t!icr  that  may 

unfit  him  for  militar;. 

1198.  .Medical  officers  attending  recruiting  rendezvous,  will 
keep  a  record  (  Form  i  i)  of  all  tin-  recruits  examined  by  them. 
Books  for  this  purpose  will  In-  procured  by  application  to  the 
Surgeon-General,  to  whom  they  will  be  returned  when  filled. 

L194.  .As  -""ii  a-  a  recruit  joins  any  regiment  or  station,  he 
shall  In-  examined  by  the  medical  officer,  and  vaccinated  when 
it  is  required. 

i  ]!•.").  .Tin-  senior  medical  officer  of  each  hospital,  post,  regi- 
ment or  detachment,  will  make  monthly  to  the  Medical  Director, 
and  quarterly  to  the  Surgeon-General,  a  report  of  sick  and 
wounded,  and  of  deaths,  and  of  discharges  for  disability  (  Form 
l  ) :  and  transmit  t<>  the  Surgeon-General  a  copy  of  the  Monthly 
Statement  of  the  Hospital  /•''/»•/  (  Form  19). 

1196.  .After surgeon's  '-all.  he  will  make  a  morning  report  of 
t he  sick  t>i  the  commanding  officer  (  Form  1 5  >. 

nit:.  .Every  medical  officer  will  report  to  tin-  Surgeon-Gen- 
eral and  to  the    Medical    Director,  the  date  when  he  arrive-  at  a 

Btation,  or  when  he  leaves  it,  And  his  orders  in  the  case,  and  at 

the  end  of  each   month,  whenever  not  at  his  Mation.  whether  on 

service  or  on  leave  of  absence;  and  when  on  leave  of  absence, 

hi-  post-office  address  for  the  next  month. 

1198.  .They  will  promptly  acknowledge  the  receipt  of  all 
orders  relating  to  their  movements;  and  in  all  official  communi- 
cations, when  at  stations  the  positions  of  which  are  not  well 
known,  they  will  state  the  nearest  post-office. 

i  199.  .Win  n  it  i^  necessary  to  employ  a  private  physician  as 
medical  officer,  tic  Medical  Director,  or  if  circumstances  pre- 
clude reference  to  him.  the  commanding  officer  may  execute  a 

written  contract   (notifying  the  Medical  Director),  c litioned 

a- in   Form  16,  at  a  stated  compensation,  not  to  exceed 

nth  when  the  number  of  officers  and  men.  with  authorized 


APPENDIX.  457 

laundresses,  is  LOO  or  more  ;  $40  when  it  is  from  ."><>  to  LOO,  and 
$30  when  it  is  under  50, 

1200.  .Bui  when  he  is  required  to  abandon  his  own  business, 

and  give  his  whole  time  to  the  public  service,  the  contract    may 

he  not  to  exceed  $80  a  month;  and  not  to  exceed  ^i<»n,  besides 
transportation  in  kind,  to  he  furnished  by  the  Quartermaster's 
Department,  where  he  is  required  to  accompany  troops  on 
marches  or  transports,  But  a  private  physician  will  not  he 
employed  to  accompany  troops  on  marches  or  transports,  except 
by  orders  from  the  War  Department,  or.  in  particular  and 
urgent  eases,  by  the  order  of  the  officer  directing  the  movement. 

1201.. And  when  a  private  physician  is  required  to  furnish 
medicines,  he  will  he  paid,  in  addition,  from  twenty-live  to  fifty 
per  cent.,  to  he  determined  by  the  Surgeon-General,  on  the 
amount   allowed  hv  contract. 

1202.  .In  all  cases,  a  duplicate  of  the  contract,  with  a  par- 
ticular statement  of  the  circumstances  which  make  it  accessary, 
appended,  will  he  transmitted  forthwith  to  the  Surgeon-General 
lor  approval;  ami  the  commanding  officer  tor  the  time  being 
will  at  once  discontinue  it,  whenever  the  necessity  tor  it  ceases, 
or  the  Surgeon-General  may  so  direct. 

1203.. The  physician's  account  of  pay  due  must  he  sent  to 
the  Surgeon-General  tor  payment,  vouched  by  the  certificate  of 
the  commanding  officer,  that  it  is  correct  and  agreeable  to  con- 
tract, and  that  the  services  have  been  duly  rendered,  lint  on 
the  frontier  or  in  the  field,  when  it  cannot  conveniently  he  sub- 
mitted    to    the    Surgeon-General,    the    contract    having    already 

received  his  approval,  tie-  account  may  lie  paid  on  the  order 
of  the  commanding  ollicer,  not  to  exceed  'he  regulated  amount, 
by  a  Quartermaster  or  a  medical  disbursing  officer. 

1204.  .Private  physicians,  employed  by  contract,  will  conform 
to  the  regulations,  and,  accordingly,  will  keep  all  the  records, 
and  make  tin'  reports,  requisitions  and   returns  required  from 

medical   officers. 

L205.  .When  medical  attendance  is  required  by  ollicer-  or 
enlisted  men  on  service,  and  the  attendance  of  a  medical  officer 
cannot    he   had.   the   officer,  or   if  there    he   no   ollicer.   then   the 


i.> 


APPENDIX. 


enlisted  man.  may  employ  a  pr irate  physician,  and  a  jus!  ac- 
eount  therefor  will  be  paid  by  the  Medical  Boreas. 

1906.  .The  account   will  set  nut   the   name  of  tin-  patient,  tlie 

date  nt'  and  charge  for  each  \i~it.  and  for  medicines.  The  phy- 
sician will  make  a  certificate  t"  tlif  acoouat  in  case  ofaa  officer, 

Or  affidavit  in  ease   of  an   enlisted   man.  that   the  account  is  cor- 
rect, and  the  charges  are  the  customary  charges  of  the  place. 
1807.  .The  officer  will   make   his  certificate,  or  the  enlisted 

man  hi-  affidavit,  to  the  correctness  Of  the  account,  that   he   was 

on  service  at  the  place,  and  stating  the  circamstauocs  prevent- 
inLr  him  from  receiving  the  services  of  a  medical  offieen 

1208.  .When  the  charge  is  against  an  officer,  he  will  pay  the 

aecount,  if  practicable,  and    transmit    it   to  the   Medical    Bureau 

for  reimbursement.  In  all  other  cases,  the  account  will  he 
transmitted  to  the   Medical    Bureau  for  settlement. 

1209.  .If  the  charge  is  against  a  deceased  officer  or  enlisted 
man.  the  physician  will  make  the  affidavit,  before  required,  to 
the  account,  ami  that  he  has  been  paid  no  part  of  it. 

L210.  .No  charges  tor  consultation  tecs  will  he  paid  by  the 

.Medical  Bureau;  DOT  will  an\  account  for  medical  attendance 
or  medicines   he   paid,  it'  the   officer  or  enlisted   man   he   not   on 

service. 

1211.  .A  board  of  not  less  than  three  medical  officers  will  he 
appointed  from  time  to  time,  by  the  Secretary  of  War.  to  exam- 
ine applicants  for  appointment  of  assistant  surgeons  in  the  reg- 
ular army,  and  assistant  guasjCOns  tor  promotion.  And  no  one 
shall  he  so  appointed  or  promoted  until  so  examined  and  found 
qualified. 

121 -.'..The  board  will  scrutinize  rigidly  the  moral  habits, 
professional  acquirements,  and  physical  qualifications  of  the 
candidates,  ami  report  favorably,  either  for  appointment  or 
promotion— ho  no  case  admitting  of  a  reasonable  doubt. 

1218. .  The  Secretary  of  War  will  designate  the  applicants  to 
bi>  examined  tin-  appointment  of  assistant  Burgeon.     They  must 

he  between  twenty-one  and  t\vent\-li\e  years  of  age.  The 
hoard  will  report  their  respective  merits  in  the  several  branches 
of  the  examination,  and  their  relative  merit  from  the  whole; 
agreeably  whereto,  if  vacancies  happen  within  two  years  there- 


ArrENDix.  48i 

after,  thev  will  receive  appointments  and  take  rank  in  the  medi- 
cal corps. 

1214.  .When  HO  assistant  Burgeon  lias  served  five  years,  he  is 
subject  to  be  examined  for  promotion.  It'  he  declines  the  exam- 
ination, or  be  found  not  qualified  by  moral  habits  or  professional 
acquirements,  he  ceases  to  be  a  medical  oflicer  of  the  army. 

1215.  .An  applicant  for  appointment  foiling  at  one  examina- 
tion, may  be  allowed  a  second  after  two  years;  but  never  a 
third. 

1216.  .The  Secretary  of  War  will  appoint,  on  the  recom- 
mendation of  the  Surgeon-General,  from  the  enlisted  men  of 
the  army,  or  cause  to  be  enlisted,  as  many  competent  hospital 
stewards  as  the  service  may  require* 

121 7..  The  senior  medical  oflicer  of  a  command  requiring  a 
steward,  may  recommend  a  competent  non-commissioned  officer 
or  soldier  to  be  appointed,  which  recommendation  the  com- 
manding officer  shall  forward  to  the  Adjutant  and  Inspector- 
general  of  the  Army,  with  his  remarks  thereon,  and  with  the 
remarks  of  the  company  commander. 

L 218.  •  When  no  competent  enlisted  man  can  be  procured) 
the  medical  officer  will  report  the  fact  to  the  Surgeen-General. 
Applications  and  testimonials  of  competency,  from  persons  seek- 
ing to  be  enlisted  for  hospital   stewards,  may  be  addressed  to  the 

Surgeon-General. 

1219.  .The  commanding  oflicer  may  re-enlist  a  hospital  stew- 
ard at  the  expiration  of  his  term  of  service,  on  the  recommenda- 
tion of  the  medical  officer. 

1220.  .No  soldier,  or  citizen,  will  be  recommended  for  ap- 
pointment  who   is    nod    known  to  be    temperate,   honest,   and    in 

every  way  reliable,  as  well  as  sufficiently  intelligent,  and  -killed 
in  pharmacy,  for  the  proper  discharge  of  the  responsible  duties 
likely  to  he  devolved  upon  him.  Until  this  is  known,  he  will  be 
appointed    an    acting   steward   by   the    medical   oflicer,   with   the 

approval  of  tin-  commanding  officer,  ami  will  be  entitled  to  the 

pay  and  allowances  of  hospital  steward. 

1221.  .Hospital  steward-,  appointed  by  the  Secretary  of  War, 
whenever  stationed  in  places  whence  noposl  return  i>  made  to 
the    Adim-ant-General's  office,  or  when  on  furlough,  will,  at  tl,. 


460  APPENDIX. 

end  of  every  month,  report  tbemselvee,  1>\  letter,  bo  the  Adju- 

tanl   General    and    Snrgeon-(  Jeiieral.   a-    well    as   to   the    Medical 

Director  of  the  military  department  in  which  they  ma\  l>e  serv- 
i : i lt  :  i"  each  of  whom  they  will  ako  report  each  new  assign- 
ment to  duty,  or  ehange  of  Btation,  ordered  in  their  case,  noting 
carefully  the  amnber,  date,  ami  sowrea  <>f  the  order  directing 
tie'  same.  They  will  likewise  report  monthly,  when  on  fur- 
lough, to  the  medical  officer  in  charge  of  the  hospital  to  which 
they  arc  attached. 

1 222 .  . The  jurisdiction  and  authority  of  courts  martial  arc 
the  same  with  reference  to  hospital  steward-  as  in  the  eases  of 
other  enlisted  men.  When,  however,  a  hospital  steward  is  sen- 
tenced by  an  inferior  court  to  be  reduced  to  the  ranks,  such  sen- 
tence, though  it  may  he  approved  by  the  reviewing  officer,  will 
not  be  Carried  mto  effect  until  the  ease  has  been  referred  to  the 

Secretary  of  War  for  final  action.  In  these  eases  of  reduction, 
the  application  of  the  man  for  discharge  from  service,  though 
not  recognized  as  of  right,  will  generally  be  regarded  with  fewer, 
if  bis  offence  has  not  been  of  too  serious  a  nature,  and  especially 

When  he  has  not   been  recently  promoted  from  the  ranks. 

1  22S  .  .  As  the   hospital   stewards,  appointed    by   the    Secretary 

of  War,  are  permanently  attached  to  the  Medical  Department, 

their  accounts  of  pay,  clothing,  fitC.,  must  be  kept  b\  the  medi- 
cal officers  under  whose  immediate  direction  they  are  serving, 
who  are  also  responsible  for  certified  statements  of  such  accounts, 
and  correct  descriptive  lists  of  such  stewards,  to  accompany 
them  in  case  of  transfer;  as,  also,  that  their  final  statements  and 

certificates  of  discharge  are  accurately  made  out,  when  they  are 
at  length  discharged  from  service. 


APPFAIUX. 


463 


Standard  Supply  Table  for  General  and  Post  Hospitals. 

[In  General  Hospitals  detached  from  troops.  Hie  supplies  for  every  LOO  sirk  will 
correspond  with  the  allowance  u>  commands  at  600  men. 


ARTICLES. 


Quantities  for  one  year  fur  commands  of 


From 
100  to 
U0, 


From 

200  to 

300. 


From 

300  to 

4110. 


600 
men. 


1,000 
men. 


MEDICINKS. 


Acacise 11>. 

Acidi  acctici ll>. 

arseniosi >z. 

benzoic] <iz . 

"      oitrici lb. 

muriatici lb. 

nitrici ll>. 

Sulphurici lb. 

aromatiei.  ..lb. 

tannici oz. 

i;u  tarici lb. 

-  ralphurici  loti lb. 

Alcoholis bott. 

Aliuninis lb. 

Ammoniaeia  . .  .* lh. 

Ammonite  carbonal is oz. 

miiriiif  is Hi. 

AnthemidSs lb. 

Antimoniiet  potass,  tartratis.oz. 
Argenti  nitratia  i  crystals).  ■  .oi. 

{fused  e. 

\  rnicae lb. 

.\  ssafcel  idm >■/.. 

Bismuthi  bu  bnitral  is z. 

Camphors ll>. 

Cardamomi z . 

Catechu 11,. 

Cera  alb»« Lb. 

Ccrati  resinse lb. 

sitoplicis lb. 

zim-i  carbon atis lb. 

Chloroform! 11>. 

Collodii oz. 

Copaibas  lb. 

i OB. 

Cretse  preparatm lb. 

Capri  Bulpbatis >z. 

ri  ad  ha;  ivi vis. 


2 

4 

6 

8 

1 

1 

2 

2i 

i 

1 

2 

-!■ 

1 

2 

3 

4 

1 

2 

3 

4 

4 

1 

2 

2i 

l 

2 

3 

i 

l 

a 

0 

I 

l 

2 

3 

4 

2 

4 

6 

8 

2 

4 

6 

8 

2 

4 

6 

8 

24 

48 

72 

96 

1 

o 

3 

4 

J 

1 

2 

2i 

8 

16 

21 

32 

i 

1 

2 

2i 

1 

2 

:: 

1 

3 

6 

9 

12 

1 

•2 

3 

4 

1 

2 

3 

4 

1 

o 

3 

1 

4 

8 

12 

16 

4 

8 

12 

M 

2 

4 

6 

s 

8 

16 

24 

32 

J 

1 

2 

2\ 

2 

4 

6 

8 

2 

4 

6 

8 

8 

ie 

21 

32 

2 

4 

6 

8 

1 

2 

3 

1 

2 

4 

6 

- 

5 

lu 

15 

20 

2 

4 

6 

8 

1 

2 

3 

4 

2 

1 

6 

8 

5 

10 

15 

20 

L6 

5 
5 


8 
16 

16 

16 

lit  2 

8 

5 

64 

5 

8 

24 

8 

8 

8 

32 

38 

16 

U 

5 

16 

16 

u 

16 

8 
16 

in 
16 

8 
16 

hi 


•  To  be  Issued  t..  posts  where  slmpli  cerate  i  inuol  i  •   nenl  without  b< 

raw  ill. 


462 


APPENH1.V 


SUPPLY   TAI'.I.K    KUi:    IIOHPH  \l  -      Continued. 


AHTK  l.i:>. 


quantities  for  one  year  f.>r  commandi  "f 


LOO  to 

no. 


From 
900  to 


Prom 
800  to 

too. 


nun. 


Euiplastri  c&ntharadia lb. 

ferri lb. 

"        hydrargyri U>. 

"        ictbyooollae yds« 

Extracti  belladonna oz. 

"      bacha  Qaidi 1 1  >  - 

"      oolocyntbidis,  comp.oz. 

"      oolombse  fluidi lb. 

"       couii ox. 

"      qnbebse  fluidi lb. 

"       gentians?  fluidi lb. 

"      glycyrrhizse lb« 

"      hyosoyami ob. 

"  ipecacuanha  Quidi. .  1 1  >  - 
piperia  fluidi z< 

"  pruni  rirg.  fluidi. .  .lb. 
rhei  fluidi lb. 

•'      Barsaparillse  fluidi.  .ll>. 

s  i  ■  H  i  ■  lT  :  t  ■  lluidi lb. 

seuuae  lluidi lb. 

"'        tara.xai-i   llui'li lb. 

"  Valerianae  lluidi. . .  .oz. 
zingiberis  fluidi . . .  .lb. 

Ferri  iodidi «/.. 

"     et  quinia>citratis oz. 

"     Buipbatia >■'■■ 

Gambogia oz  • 

Glycerine >/.. 

(luaiari  reeina lb. 

Hydrargyri  cbloridi  oorr. . .  .oz. 
"  "         miiis  ..  .lb. 

"  cuni  oreta lb. 

iodidi oz. 

oxidi  rubri /.. 

[odinii n  • 

Lini lb. 

Li(|iioris    A  m 1 1 1 ' . i >  i^i- lb. 

"      ferri  iodidi lb. 

"      potass  :  araenil is /.. 

•'      Bodse  cblorinatflB  •  •  I 

"      zinoi  chloridi  . .  •  .bo(  I  ■ 

Magnesia lb. 

Bulpbatie ll>. 


3 

6 

9 

12 

1 

9 

3 

4 

i 

1 

2 

2i 

3 

G 

9 

12 

2 

4 

6 

8 

1 

I 

.      3 

I 

8 

16 

24 

32 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

•1 

6 

12 

18 

24 

2 

4 

6 

8 

i 

1 

2 

H 

1 

•> 

3 

4 

1 

■1 

3 

4 

1 

0 

3  • 

4 

2 

4 

0 

8 

1 

1 

2 

n 

1 

2 

3 

4 

1 

2 

3 

4 

1       8 

lti 

24 

32 

1 

1 

2 

2i 

2 

4 

6 

8 

4 

8 

12 

16 

2 

4 

6 

8 

A 

1 

2 

2i 

0 

4 

6 

s 

A 

1 

2 

l\ 

i 

1 

2 

2i 

1 

2 

3 

4 

J 

1 

2 

2i 

1 

2 

3 

1 

1 

2 

8 

4 

2 

4 

6 

8 

I 

8 

12 

Hi 

■1 

8 

12 

16 

1 

2 

3 

-1 

2 

A 

6 

8 

8 

6 

g 

12 

8 

6 

9 

12 

a 

1 

2 

2i 

25 

50 

75 

Kin 

* 


,\PPKNIHX. 


SUPPLY  TABLE  FOR  HOSPITALS  Omtnnu-d. 


463 


Quantities  t"ir  one  year  for  commands  of 


From 

Kin  to 

aoo. 


Prom   I   Prom 

aoo  to  j  a > 

300.  400. 


.,iiii 
men. 


1,000 
men. 


M:i--;r  ]iil  :  hydrargi oz 

Mollis  despumati lb 

Morphite  snlpbatis <lr 

Myrrhse lb 

Olci  anisi >7. 

•■    cajupoti oc 

"    oaryepbylli <>/. 

"    cinnamomi om> 

"    menthse  piperita <•/. 

••    motrhusa botl 

"    olivae botl 

"    origami Ir 

••    ricial (Jt.  bott 

••    terebintbinse it.  botl 

•'    tiiilii dr 

Opii  .'. Lb 

Pieia  abietia .  .lb 

Plnmbi  aeetatia lb 

Potasse  aeetatia lb 

biearbonal  is lb 

"      bitartratia lb 

'•       ckloratia lb 

nitratis lb 

"      talpbatia lb 

Potassii  i-VMiiureti dr 

iodidi 07. 

Pruni  virginiana* lb 

Ptilveris  acaciae lb 

"         aloes 07. 

"       eantharidia >z 

•'       oapaici lb 

"        Binohonee lb 

"        forri oz 

per  sulphatia.  .oz 

"        glycyrrhizae »/. 

ipecaeoatihsB lb 

"  "  et  opii.  .lb 

"       lalapae i 

'lini lb 

Opii Hi 

"  rbci lb 

■abioa  ....   i 

Pulvoris  siiiajii.-  aigTC lb 


s 

16 

24 

32 

2 

4 

6 

8 

2 

4 

I) 

8 

1 

1 

2 

24 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

4 

3 

4 

0 

e 

8 

Hi 

24 

32 

8 

Hi 

21 

32 

4 

8 

12 

10 

12 

24 

36 

4* 

4 

8 

12 

16 

2 

4 

6 

8 

1 

1 

2 

24 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

4 

1 

2 

3 

4 

2 

4 

6 

8 

1 

<) 

3 

4 

1 

2 

3 

4 

4 

1 

2 

24 

l 

2 

3 

4 

8 

li; 

2  1 

32 

4 

l 

2 

24 

2 

4 

li 

8 

4 

8 

12 

16 

2 

4 

C 

8 

1 

2 

:; 

4 

1 

2 

3 

4 

2 

4 

6 

s 

1 

2 

8 

4 

4 

8 

12 

16 

4 

1 

2 

24 

J 

1 

2 

24 

t 

3 

12 

H 

8 

in 

24 

32 

1 

2 

1 

4 

i 

1 

1 

2 

i 

4  I 

6 

12 

L8 

94 

4i;t 


APPENDIX. 


si  IMM.V   TABLE   FOP    HOSPITALS-  Continued. 


Quantities  f..r  rme  jr«ur  for  commandi  of 


Prom 
300. 


from 

4(Mi. 


500 
men. 


1  ooo 

nun. 


I'uh  eria  nlmi Il>. 

Qnassise Hi. 

Qaiuise  rolphatia /• 

Rhci oz . 

Saccbari lb. 

Saponia Lb. 

Si-illa- * oz. 

Barpentarisa lb« 

Sodae  bicarbonatk lb. 

boratia Hi. 

h  potaaa  ;  tartratia  ...  Hi. 

Spigelian Hi. 

Spiritua  ami :  aromal  i'i.  .oz. 

"      aatheria  compoaiti ...  Hi. 

"  "        nilrici Hi. 

"       liiviiniliil;i    com  p. .  .  .Hi. 

"      villi  g&llici bott. 

Strychnia Ir« 

Balpharis  loti lb. 

B|  rapi  Boillae lb. 

Tinctures  aconiti  radicie lb. 

"        digitalis oz. 

"        ergotaa  (Dublin)  .  .oz. 

"         I'crri  chloridi lb. 

"         \  eratri  veridia >/. . 

CTnguenti  hydrargyri lb. 

"  •'  nil  nitis.  .  lli. 

Vera!  rise lr« 

Vini  colchici  aeminia Lb. 

Zinci  acetatia "/. . 

"      clilnriil ii/.. 

"     aulphatia iz. 

i\s  I  i:i  mi  m  B. 

A  mputating Beta . 

Ball  foraepa no. 

1 : ■  i n ^  i i ■  > .  u. 1 1 1 1 1  elastic  (1  to  12)  no. 
metallic  (assorted  I. no. 
I  *  in  K "  -  apbn    i  holder  for  the 

throal  n<>. 

Catheters*  gum  ela  I Lc  (2  i" 

I") in,. 


2 

4 

6 

8 

I 

1 

2 

10-20 

20-10 

30-60 

in  SO 

• 

8 

12 

16 

20 

•10 

60 

Ml 

< 

8 

12 

16 

1 

s 

ll' 

16 

4 

1 

•1 

1". 

2 

4 

6 

8 

4 

1 

2 

24 

3 

0 

'.i 

IL- 

4 

1 

2 

24 

•1 

4 

6 

B 

4 

1 

2 

n 

2 

1 

6 

8 

4 

1 

J 

12 

24 

36 

US 

1 

2 

:; 

-1 

1 

2 

:'. 

-l 

3 

ii 

9 

12 

1 

_' 

:i 

4 

4 

8 

12 

Hi 

■1 

8 

12 

Hi 

A 

1 

2 

a 

4 

8 

12 

16 

1 

2 

3 

4 

i 

1 

2 

24 

I 

2 

3 

4 

4 

1 

2 

2j 

i 

2 

3 

1 

4 

1 

1 

2     l 

i 

2 

3 

1 

i 

1 

1 

1 

i 

1 

1 

1 

6 

B 

'•■ 

I 

6 

ii 

6 

fi 

1 

I 

I 

1 

(i 

ii 

i 

B 

In 

5 
BO  100 
32 
1 60 
32 
32 

I 
16 

5 
L'l 

5 

in 

E 
M 

j 
«J6 

8 

i 

L'l 

8 
32 
82 

5 
32 
B 
5 
3 
j 
8 
3 
8 


APPKNDTX. 


465 


SUPPLY  TABLE  FOR    HOSPITALS— Continued. 


Quantities  for  one  year  for  commands  of 


Prom 

100  to 

200. 


Prom 

200  to 

800. 


<  lathetera,  silver  I  3,  6,  9  I.  •  •  .no. . 

"  eases no.  . 

Capping  glasses,  or  tina  • . .  .no. . 

Dissecting ?eis. . 

Lancets,  spring4 no. . 

y       tfaumbf no. . 

Needle?,surgeons',  with  cast  s.no. . 

Obstetrical sets. . 

Pocket seta.. 

Probangs no. . 

Pulleys seta. . 

Scarificators no. . 

Splints  (assorted) sets. . 

Stethesoopes no. . 

Stomach  pump  and  ease  .  .  .  .no.  . 

Syringe,  enema} no. . 

junis.  glass no.  . 

metallic no.  . 

''      vagina|| no. . 

Teeth  extracting sets. . 

'I  ongue  depn  ssor  (hinge  I. .  .no.  • 

Tourniquets,  field no. . 

spiral no. . 

Trepanning set-. . 

Trocars  |  I  small) no. . 

Trusses,  hernia no. . 


Anatomy cop. 

Chemistry oop.. 

I  lispensatory p. 

Medical  Dictionary cop. 

Formulary sop. 

Jurisprudence   and 
Toxicology oop. 

Practice cop; 

Obstetrics oop. 

I;,  gulationt  for  Med.  Dapl  .cop. 

V 


3 

3 

3 

3 

1 

1 

1 

1 

12 

12 

is 

IS 

1 

1 

1 

1 

1 

1 

1 

1 

2 

2 

3 

t 

6 

6 

<i 

G 

1 

1 

1 

1 

1 

1 

1 

1 

6 

G 

fi 

G 

1 

1 

1 

1 

2 

2 

2 

3 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

3 

3 

3 

3 

2 

4 

G 

s 

6 

12 

18 

24 

3 

3 

3 

3 

1 

1 

1 

1 

1 

1 

1 

1 

4 

4 

6 

G 

1 

1 

0 

2 

1 

1 

1 

1 

1 

I 

1 

1 

3 

6 

9 

12 

1 

1 

1 

1 
1 

1 

: 

i 

2 

i 

I 

3 
1 

21 
1 
2 
6 

12 
1 
I 
G 
1 
4 
1 
1 
1 
6 

16 

36 
6 
2 
2 

10 
4 
1 
2 

24 


Pom  extra  M.  ami  to  each  lancet, 

f With  I 


|  ( inc  Davidson's;  one  4  <■■/. 
l  bard  India  rubbery  -1  glass. 


466 


APPENDIX. 


SUPPLY  TABLE  FOB    HOSPITALS    -Coutiuued. 


A.RTII  l.i.v 


Qu.tiit.'  tt  tat  <-  .niiii.-iii.i-.  ..f 


K'r.'iii 

100  to 

200. 


Ki .  'in 

too. 


I 


500 
man. 


1,000 

MUM. 


Blank  

Case no. 

• Irder  and  Letter no. 

Prescription do. 

Register bo. 

Requisitions ~\ 

Retains do. 

Reports  of  si«'k.  .  .  I 

HOSriTAI.  STORES. 


Arrowroot lb. 

Barley lb. 

Cinnamon lb. 

Cloves ( '  /. . 

Cocoa lb. 

Farina ll>. 

<;  Lnger,  gronnd  |  Jamaica).  ■  -lb. 

N  atmege oz. 

Tea li>. 

Whiskey,  bottles  of <loz. 

Wine,  bottles  of doz. 


Bed  sacks no. 

I-,   iron no. 

Blanketaj  woollen no. 

<  loverleti ii". 

G/Utta  perch  a  cloth yde. 

Matl  resaei no. 

MusquitO  liars no. 

Pillow  cases no. 

ticks no. 

Sheets no. 

Ki'UMT'  BB,  DBBBBIMQ,  STO. 

Banda  res,  in  ipensory  ' do. 

Lrdsl no. 

c  rl.s.  as-  irted doi. 

( '..rk  Borewi no. 


2 

2 

2 

3 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

5 

10 

„ 

20 

20 

10 

60 

Ml 

J 

1 

•J 

1 

8 

12 

16 

10 

•Jii 

30 

10 

6 

10 

15 

20 

* 

1 

2 

2A 

4 

s 

12 

10 

20 

10 

60 

so 

2 

1 

6 

8 

2 

4 

6 

8 

in 

20 

.".0 

40 

6-10 

12-20 

19  50 

24    in 

in  l'ii 

20   lo 

30  no 

10  so 

10 

L'o 

30 

10 

■I 

I! 

s 

10 

■> 

1 

15 

- 

6-10 

1L'    L'O 

!<  30 

21    10 

•j 

so 

75 

loo 

in 

20 

30 

in 

so 

120 

L'iio 

1 

8 

]■: 

16 

1 

6 

s 

12 

12 

24 

36 

w 

1 

1 

■J 

2 

10 

160 

5 

32 

BO 

10 

5 

::_• 

100 

10 

16 


80 

;-  50 

bo  ieo 

so 

10 

16 

I-    so 

200 

v,| 

400 


32 

16 
90 


|  18  Inches  »j  4. 


APPENDIX. 


467 


SUPPLY  TABLE  FOR   HOSPITALS— Continue). 


Quantities  for  one  year  for  commands  of 


From 

200  to 

300. 


Prom 
800  to 

4(10. 


500 
men. 


Cotton  batting lb. . 

"      wadding lb. . 

Flannel,  red v. Is. . 

Funnels,  glass no. . 

tin no.  . 

Hatchets no. . 

Hones  (in  wood  )• no.  . 

Ink  powder papers* . 

Inkstands no.  . 

Lini  n   yds.  . 

Lint .lb.. 

Measures,  graduated no.. 

"         tin sols. . 

Medicine  cups  and  glasses^  .no. . 

Mills,  coffee no. . 

Mortars  and  pestles,  glaas  ..no.. 

"  '•  "  iron  .  .  .  no.  . 

"          "        "        wedge- 
wood  no. . 

Muslin yds. . 

Needles,  sew  in  g no.  . 

Oiled  silk,  or  gutta  pcnlia 
tissue.  Or  India  rubber  I  is- 
sue   yds. 

Pans,  bed no. 

Paper  envelopes} no-. 

Paper,  filtering quires. 

wrapping qnires. 

"     writing! [uirea. 

Pencils,  hair no. 

"  lead no. 

Pencils,  steel doe. 

Pill  boxes papers. 

mach|ne no. 

Pins,  assorted papers. 

.Quills no. 

Rain  guagei no. 

Razors no. 

Elaior  strops no. 

Scabs   and    Weights,  aputbe- 

eary's sets. 

.  sir  p  .  .sets. 


1 
1 

5 
1 
1 
1 

1 
2 

1 
5 
4 
9 
1 
3 

2 

1 
1 

1 
25 

25 


4 
2 

Inn 

i 

10 

12 

12 

6 

2 

3 

1 

2 

25 

1 

1 

1 


10 

1 
1 
1 
1 

2 
1 

10 

6 
3 

1 

e 

2 

1 
1 

2 
50 
25 


125 

1 

12 

20 

18 

g 

f. 
1 
I 
25 
1 
1 
1 


3 

1 
4 

1 

4 

15 

20 

2 

2 

2 

2 

2 

2 

1 

1 

3 

:; 

2 

•  2 

15 

20 

s 

HI 

4 

6 

1 

1 

9 

12 

2 

3 

2 

2 

1 

1 

2 

3 

75 

Kill 

25 

26 

6 

8 

s 

4 

150 

200 

2 

2 

15 

Li 

20 

20 

24 

30 

111 

12 

3 

4 

9 

12 

1 

1 

9 

s 

50 

1 

1 

1 

1 

1 

1 

2 

2 

1 

1 

*4  inches  by  1.    +_  cupa  to  l  trin~- .    {Assorted,  8  sizes — '-iiiiirijii  business" 
printed  on  each.    ,  Foolscap,  letter  and  note — white;  bine  ruled. 


hl\ 


81  ITI.\    T  \r.l  i:   FOB    HOSPIT  kL8 


DO. 

DO. 

Silk,  surgeons' /•• 

•'     (CM" .v,1>- 

Spatulas ii". 

Sponge lb. 



Thermometers  and  hydre- 

Mi'  tei ii". 

Thermonu  ters no. 

Thread,  line /. 

• In  i. 

T..W  lb. 

Towels ii"- 

Tn  ine 1  • » - 

Urinals to. 

iMorted 'l<>/.. 

DO. 

W  i  e,  sealing sticks. 


•J 

1 

i 

. 

4 

l 

3 

1 

i 

l 

i 

2 

■ 

1 

i 

' 

•• 

3 

i 

2 

-ii 

30 

i 

1 

2 

3 

6 

13 

1 

1 

3 

3 

8 
i 

•l 

12 

2 

l 

a 
2 

jit 

'! 

5 
18 

2 

i 


10 

6 

I 

16 

2 
1 

0 
S 
3 

I 

l 


i 
13 

I 

l." 

1 

2 

I 

! 
1J0 

III 

8 

c 


i  toe  quarter,  woolli  n  ;  thn  e  qua 


if  the  following  artiok     o(    B     pital  Furniture  cannot   be  o 
witli  the  hospital  fond,  they  may  be  procured  from  ;i  qnssrsn  master  "t- 
medical  disbursing  officer,  by  special  requisition: 


Basins,  trash. 

Bowls. 

Box«  -.  i"r  i"  pper 

Buckets. 

Cloth      ; 

Dippi 
ii  rati  1 1. 


AKTM   I  I   9. 

Gridirons. 
Kettli  -.  tea. 
and  K  ni\  es  and  Forki 

I    r  1 1  - . 

Locks  add  K  ej  -. 

Mo. 

Pans,  i>;  ing. 

•• 
Pitchi 
s.       Plates. 


Pots,  i  and  ti 


••    iron. 
Sadiron  -. 

.  lire 
Skillet,  » Itb 
Snuffers. 
Spoons. 
i  n  I  ] 

Tumblers. 

i«  s. 


shambor  X  chair.l 


AIMT.NDIX. 


469 


Standard  Supply  Table  for  Field  Service. 


Ql  im  mi  IS. 


Iteg't        Bat.        Comp. 
:;  urns.     :;  mos.     3  inos. 


M  l.l'K   IM>. 


Acidi  nitrici lb. 

sul ph.  aromatici lb. 

bantiioi oz. 

Aleoholia bott. 

A  him  In  i- Hi. 

A  in  in  "II  i;>'   ciili'iiiMlis iz . 

Aiitiiii'iini  *■:  potass,  tartratria <>z- 

i  aitratis  (fused) ■■ 

<    Dill  ]'ll     IM' lb. 

Ceral  i  resrnae lb. 

si  in  pli'  i.- II). 

Chloroformi 11>. 

Copaibae lb- 

I  '  1  i   B  .-  "  ,  i OZ  . 

Capri  Bulphatis oz. 

Emplastri  adhoesivi j  da . 

cantharidia Lb. 

"  irhtl  iv  ncil  he yds. 

Extract i  eolocynihidia  comp oz. 

glycyrrhisse lb. 

Bydrargyri  chloridi  oorrosivi •  • 

niitis lb.  i 

lud in ii m  . 

Liquoru  ammonite lb. . 

potass,  arson itis ■/.  ■ 

Magnesias  sulphatu Lb. . 

pil.  bydrargyri 

Morphia  Bulphatic dr. . 

Olei  menthae  piperita ....«/... 

"      olivu In.  II.. 

ricini |i. 

berebinthinse |t.  bott.. 

ti^'lii ilr.  . 

Pil nl :  cathartic :  comp:  (U. 8.) doe. . 

opii  (U.S.) 

Plnmbi  aeetatu lb. . 

i  11... 

chlorati Lb. . 

oitratii lb. . 

P  'l.i  --ii    i.i'li  ii ../.  . 

Palreria  acacia lb. . 

"  <• « l > s i e i lb.  . 


• 

i 

i 

1 

4 

2 

1 

6 

4 

1 

i 

16 

8 

2 

1 

-1 

2 

4 

2 

2 

1 

8 

4 

2 

1 

2 

1 

2 

1 

4 

2 

15 

8 

4 

2 

2 

1 

16 

8 

2 

1 

i 

i 

2 

1 

4 

2 

4 

2 

4 

2 

25 

1* 

Hi 

s 

4 

2 

2 

1 

- 

4 

12 

6 

- 

4 

2 

1 

S 

4 

8 

4 

2 

1 

2 

1 

2 

1 

1 

I 

8 

4 

1 

9 

! 

1 
« 

470 


APPENDIX. 


SUPPLY  TABLE   FOR   FIELD  SERXICE    -Continued. 


Ijl    \N 


:;  mas. 


Bat. 
.",  mas. 


C  imp 

3  mow. 


Pulveris  ferri  per  sulphatis 01 

'•  ipi-  :i'U;inh;>' Lb 

et  opii II) 

lini 11. 

"        opii Hi 

rkei lb 

"        sinapis  aigrsB lb 

Qui nia-  sulphatie oz 

Saoehari lb 

Saj  urn  is lb 

Bo4n  bicartonatis lb 

Spiritus  ammonia  aromaaioi oi 

BBtheria  adtrici 11) 

\ini  gallici butt 

Syrupi  actUse lb 

Tinctures  einchonm  oomp lb 

"        columbat lb 

fcrri  chbnridi lb 

"         pentianae  comp lb 

'•         opii oz 

veratri  reridis an 

Unguonti  bydrargyri lb 

"  nitratis lb 

Vini  oolbhioi  Beminia lb 

Zinci  aoetatis oi 

•'      sulphatis oz 

INSTIll    MI'NTS. 

Amputating Beta 

Bail  forceps do 

I  dugii  t,  "inn  elastic  |  l  to  12) do 

imTallic  (assort i'il) no 

Catheters,  gum  elastic  (2  to  10) no 

silver  Ci,  C.  tl) no 

eases do 

Cuppin  v  ti do 

i  -.  spring do 

thumbs  (with  cases) no 

NTeedlot,  Burgeons  |  with  cases) no 


•1 

2 

1 

4 

1 

i 

16 

8 

2 

1 

A 

i 

12 

6 

24 

12 

in 

5 

8 

4 

i 

i 

4 

2 

1 

1 

12 

6 

:; 

2 

4 

•i 

4 

2 

1 

i 

4 

2 

16 

8 

8 

4 

1 

1 

A 

1 

1 

■v 

2 

1 

2 

1 

2 

1 

2 

1 

ti 

6 

6 

6 

C 

0 

:; 

3 

1 

I 

12 

B 

1 

l 

4 

2     | 

12 

<3     i 

Hall'  glass,  half  tin. 


APPENDIX. 


471 


SUPPLY  TABLE  FOll  FIELD  SERVICE— Continued. 


ARTICLES. 


IJl  ANTITir.S. 


Pocket Bets 

Prob&ngs ". mi 

Scarificator! no 

Splints  (assorted) sets 

Syringes,  enens  (assorted  |* no 

■'        penis,  glass no 

"  "      India  rubber no 

Teeth  extracting sets 

Tongue  depressor  (hinge) no 

Tourniquets,  field no 

"  spiral no 

Trepanning sets 

Trocars  (1  small)   no 

Trasses,  hernia no 


A  i  hi  in  my  ( surgical) cop. 

Medical  practice »p. 

Regulations  for  medical  department cop. 

Surgery  ( operative) cop. 

Thompson's  Conspectus cup. 

Blank no. 

HOSTITAI.    STORES. 


Arrow  root lb. 

Candles  (sperm  )f lb. 

Farina lb. 

Ginger  (fluid  extract) lb. 

Nutmegs oz. 

Tea*.    lb. 

Whiskey,  bottles  of doz. 


Bed   -acks no. 

Blanket!  (woolen) no. 


Reg'l 

.".  inns.      3  mos 


2 

1 

f. 

I 

2 

1 

1 

1 

4 

2 

8 

4 

8 

4 

1 

1 

1 

1 

12 

r. 

2 

i 

1 

i 

2 

i 

6 

3 

1 

1 

1 

1 

1 

5 

5 

10 

5 

2 

1 

10 

5 

1 

1 

8 

4 

30 

I.". 

3 

2 

20 

10 

30 

15     i 

*  1  Davidson's  ;  1  bard  rubber,  6  oz. 

f  To  bi  For  use  in  surgical  operations  in  the  night. 


472 


APPENDIX. 


SUPPLY  TABLE   FOR   FIELD  BERVK  E     »   intoned. 


ARTICLES 


i  Dump. 

8  mo*.     3  ni"-.     ■"•  nii-. 


Quits  perdha  cloth 

Mosquito  ban lo. 

Pillow  ticks ao. 

I  I  I :  N  I  I  i  Ki;    A.HD    DRESSINGS. 

Bandages,*  roller,  assorted loi. 

suspensory,  a  ssorted no. 

Binder's  boards  (18  inches  by  f  i no. 

Corks,  assorted Uti. 

Corkscrews no. 

Cotton  batting lb. 

wadding lb. 

Flannel  |  rod  i yds. 

Hatch*  ts •  -ii"- 

Hones  (4  inches  by  l ,  in  sroed) no. 

Ink,  2-ouane  bottles no. 

Knapsacks,  hospital^ no. 

Lanterns no. 

I.inl U>. 

Litters  ami  stretchers,  hand no. 

'•      horse;}; no. 


20 

in 

20 

10 

20 

11' 

U 

7 

12 

6 

1> 

9 

L2 

6 

2 

1 

:• 

1 

■2 

1 

5 

:: 

■2 

1 

1 

1 

IL' 

0 

•J 

1 

1 

■> 

8 

I 

10 

■i         ••         :; 

•2\        ••         a 

:t          ••          I 

:;'.        ••         :, 

i          ••         (i 

■   1   dozen.  1   inch  wi.lc,  1   yur<l  Ion; 

2 

2 

1 

J 

i 
i   \  coon  I  in  l  i"  pattern  of  sane  dimensions  with  ordinary  knapsaoks, 

and  of  light  material;  to  be  divided  into  foui mpartmeuta  or  draw- 

.  ...  ill  to  be  covered  with  oanvas.  h  i.*  bo  be  oarried  on  ■  march  or 
in  battle,  bj  a  hospital  orderly,  who  is  habitually  to  follow  the  medical 
officer.  Tin-  purpose  of  this  knapsack  is  to  'airy  such  Instruments, 
dressings,  and  medicines,  as  maj  I"-  needed  in  an  emergenoj  on  the 
march  or  in  i  he  Bold. 

|  II. .i-  lit?  i  required  for  service  on  ground  not  admitting  the  use 
..i  twe  wheeled  carriages,  to  !"■  eoasposed  or  a  canvas  bed,  similar  to 
the  present  stretcher,  and  of  two  poles,  each  sixteen  feel  long,  made 
in  seotions,  with  head  and  i">  i  pieces  constructed  i"  acl  as  stretchers 
to  kocp  tin-  poles  apsu  U 


AJt'l'E.NJJlX. 


473 


SUPPLY  TART.E  FOR  FIELD  SERVICE— Continued. 


Qi  INT1TIES. 


But. 
'■'•  mos.    3  mos. 


Comp. 
3  mos. 


Measures,  graduated,  assorted* no. 

Medicine  chests no. 

"        cups  and  glassesf no. 

panniers no« 

Moss  chests  i  see  Bete] no. 

M  ills See no. 

Mortars  and  pestles,  wedgewood  (.small)  ...no. 

Muslin yds. 

Needles,  sewing  [assorted,  in  a  case) no. 

Oiled  Bilk,  or  gutta-percha  tissue,  or  India 

rubber  tissue yds. 

Pans;  bed  I no. 

Paper  envelopes,  assorted    no. 

Paper,  wrapping mires. 

writing! quires. 

Pencils,  hair no. 

"        lead  (of  Faber's  make,  No.  2 no. 

Pens,  steel '■ doz ■ 

Pill  boxes,  wood papers . 

"  tin no. 

Tins,  assorted  |  large  and  i Lium) papers. 

Razors no. 

Razor  strops no. 

Scales  and  weights,  apothecary's sets. 

ScissoW no. 

Slicc]i  skins,  dressed no. 

Silk,  surgeons' ox. 

•'     green yds. 

Spatulas no. 

Sponge  (washed) lb. 

Store  chest no. 


20 


100 

0 

12 

21 

12 

1 

2 

ii 

4 

1 
1 

1 
I 
I 


1 
3 

1 
1 
1 

10 
25 

4 
1 

50 
3 
Ii 

12 
6 
2 
1 
6 
2 
1 
1 
1 
2 
2 
i 
i 
:; 

I 

1 


2 

1 
2 

i 

i 
i 

5 
25 

2 

1 

26 

1 

3 

6 
3 
1 

I 

6 
2 
1 
1 
1 

2 
1 
i 
4 

2 
i 

I 


■  6  ox.,  2  os.,  minim. 

t  2  cu|ps  to  I  glass. 

J  of  hard  India  rubber  or  oilier  material.     Shovel. 

."■0  letter,  2o  note,  26  lai  "  printed  on  each. 

>/2  foolscap,  o  letter,  4  note,  white:  blue  ruled. 


in 


474 


APPENDIX. 


SUPPLI  TU5I.E  FOB    FIELD   SERVICE     Continued. 


AKTICI.KS. 


qi  \s 


:t  moa. 


Bnt. 


Tape piece! 

Thread,  limn .,• 

Tiles bo 

Towels no 

II. 

Viols,  assorted  (1  os.  and  2  ot.) los 

Wafers,  i  \  oanee  boxes) tio 

Wax,  Beating Btleks 


4 

■J 

•J 

1 

2 

1 

in 

N 

1 

1 

1 

i 

1 

1 

2 

1 

NOTE   TO    F'KK<'I-;it[NG    T  Ull.K. 


m  i:niti"rr   ok   mkss   cni:5T. 


8   I !;i si n s,  tin. 

i  Boxes,  pepper  and  salt. 

ii  ( laps,  tin. 

■I  Canist<  rs  (for  tea,  coffee,  sugar 

and  batter). 
2  Dippers  and  ladles. 
I  Qrati  r. 
1  gridiron. 
1  Kettle,  tea,  iron. 

I  L'   Kni\  B8  find  forks. 

0  Kugi  i  Hi  itannia,  half  pint  I. 


I  Pan,  fry  ing. 
1  Pan,  aaaea. 
8  Plates  | 1)  and  diski  - 
1    Pot,  ir.m. 

'_'  Pete,  eoffee  ami  tea,  tin. 
12  Spoon  8,  iron:  table  if>)  and 

tea  (•). 
I  BkiHet,  with  .-over. 
I  Tray,  tin. 
t'i  Tumblers,  tin. 


The  Standard  Si  I   in  -ill  the  articles  to  be  purchased 

by  medical  pan  ej  ors,  axoepl  on  the  orders  of  the  Surgeon  General :  but 
any  l<  98  i  nanfjty  may  bo  required  or  any  article  omitted  at  the  disare-i 
tion  ol 


RXTRACTS  FROM  THE  REGULATIONS 


CONFEDERATE    STATES    AE^IY. 


"  Before  an  action,  the  Quartermaster  of  the  division  makes 
all  the  necessary  arrangements  for  the  transportation  of  the 
wounded.  He  establishes  the  ambulance  depots  in  the  rear, 
and  gives  his  assistants  the  necessary  instruction  for  tike  service 
of  she  ambulance  wagons,  and  other  Beans  of  removing  the 
wounded." 

"  The  ambulance  depot,  to  which  the  wounded  are  carried  or 
directed  for  immediate  treatment,  is  generally  established  at  the 
most  convenient  building  nearest  the  field  of  battle.  A  red  flag 
marks  its  place,  or  the  way  to  it,  to  the  conductors  of  the  ambu- 
lance,  and  to  the  wounded  who  can  walk." 

"  The  active  ambulance  follows  the  troops  engaged,  to  succor 
the  wounded  anil  remove  them  to  the  depot.  For  this  purpose, 
the  conductor  should  always  have  the  accessary  assistants,  that 
the  soldiers  may  have  no  excuse  for  leaving  the  ranks  for  that 
object." 

The  medical  director  of  the  division,  after  consultation  with 
the  Quartermaster-General,  distributes  the  medical  officers  and 
hospital  attendants,  at  his  disposal,  to  the  dep6ts  and  active 
ambulances.  He  will  send  officers  and  attendants,  when  prac- 
ticable to  the  active  ambulances,  to  relieve  the  wounded  who 
require  treatment  before  being  removed  from  the  ground.  He 
will  see  t lint  the  depots  and  ambulances  are  provided  with  the 
ary  apparatus,  medicines  and  stores.     He  will  tak 

ami  render  his  profesMonal  Services  at  the  principal  depot. 


176  APPENDIX. 

It'  the  enemy  endangers  the  depdt,  the  QuarteraMater  takei 
the  orders  of  the  General  to  remove  it.  or  i"  strengthen  its 
guard. 

The  wounded  in  the  depots,  and  the  >i«k .  are  removi 
-,,.,1,  ,i-  poasible,  to  the  bospitahi  thai  have  been  established  by 
Quartermaster-General  of  the  Ann\.  on  the  flanks  or  rear 

lit"  the  arm} . 

In  Beiges,  the  field  officer  nt'  the  trenches  Bees  thai  men  and 
litters  are  always  ready  to  bring  off  the  wounded 

No  officer  making  returns  of  property  shall  drop  from  his 
return  any  public  property  as  worn  out  or  unserviceabre  until 
it  has  1  ><  i  it  condemned,  after  proper  inspection,  and  ordered  t>> 
be  bo  dropped. 

Every  officer  having  pnbtie  money  to  account  for,  and  failing 
to  render  his  account  thereof  quarter-yearly,  with  the  Touchers 
necessary  ti>  its  correcl  and  prompt  settlement,  within  throe 
months  after  the  expiration  of  the  quarter,  if  resident  in  the 
Confederate  States,  and  within  abt  months  if  resident  in  a 
foreign  country,  will  be  promptly  dismissed  bj  the  President, 
he  shall  explain  the  default  to  the  satisfaction  of  the 
President. 

Every  officer  entrusted  with  public  monej  or  property  shall 
render5 all  prescaibed  returns  and  account-  to  the  bureau  of  the 
department  in  which  he  is  Berving,  where  all  such  returns  and 
accounts  shall  j>a<s  through  a  rigid  administrative  Bcratmy  be- 
fore the  money  accounts  are  transmitted  to  the  proper"  offices  of 
the  Treasury  Department  tin- settlement. 

The  sii-k  will  be  transported  on  the  application  of  the  medical 
officers  to  the  Quartermaster. 

Assistant  Burgeons,  approved  by  an  examining  board  and 
commissioned,  receive  transportation  in  the  execution  of  their 
first  order  to  duty. 

The  allowance  and  change  of  straw  for  the  sick  is  regulated 
bj  the  surgeons. 

Issues  to  the  hospital  will  be  on  returns  bj  the  medical  officer, 
for  Buch  provisions  onK  as  are  actually  required  for  the  sick  and 
the  attendants.  The  cost  of  Buch  parts  of  the  ration  as  are 
issued  will  be  charged  to  the  hospital  at  contract  or  cost  prices, 


Al'PENJJlX.  477 

and  the  hospital  will  be  credited  by  the  whole  Dumber  of  com- 
plete rations  due  through  the  mon tli  at  contract  or  cost  prices; 
the  balance,  constituting  the  Hospital  Fund,  or  any  portion  of  it, 
may  be  expended  ny  the  commissary,  on  the  requisition  or  the 
medical  ollicer,  in  the  purchase  of  any  article  for  the  subsistence 
or  comfort  of  the  sick,  not  authorized  to  be  otherwise  furnished, 
(see  Form  11').  At  large  depots  or  general  hospitals,  this  fund 
may  he  partly  expended  for  the  benefit  of  dependent  posts  or 
detachments,  on  requisitions  approved  by  the  Medical  Director 
or  senior  Surgeon  of  the  district. 

The  article-;  purchased  for  the  hospital,  as  well  as  those  issued 
from  the  subsistence  storehouse,  will  be  included  in  the  Sur- 
geon's certificate  of  issues  to  tin-  hospital,  and  borne  on  the 
monthly  return  of  provisions  received   and  issued.     Vouchers 

tin  purchases  for  the  hospital  must  either  be  certified  by  the 
surgeon   or  accompanied   by  his  requisition. 

Abstracts  of  the  issues  to  the  hospital  will  be  made  by  the. 
commissary,  certified  by  the  surgeon,  and  countersigned  by 
the  commanding  officer. 

An  extra  issue  of  fifteen  pounds  of  tallow  or  ten  of  sperm 
candles,  per  month,  may  be  made  to  the  principal  guard  of 

each  camp  and  garrison,  on  the  order  of  the  commanding  ollicer. 
Extra  issues  of  soap,  candles,  and  vinegar,  are  permitted  to  the 
hospital  when  the  surgeon  does  not  avail  himself  of  the  commu- 
tation of  the  hospital  rations,  or  when  there  is  no  hospital  fund; 
salt,  in  small  ipiantities.  may  be  issued  for  public  horses  and 
cattle.  When  the  officers  of  tin-  Medical  Department  find  anti- 
scorbutics necessary  for  the  health  of  the  troops,  the  command- 
ing officer  may  order  is-ues  of  fresh  vegetables,  pickled  onions, 
sourcrout.  or  molasses,  with  an  extra  quantity  of  rice  and  vine- 
gar. (Potatoes  are  usually  issued  at  the  rate  of  one  pound  per 
ration,  and    onions  at    tin'  rate  of  three  bushels  in  lieu  of  on,-   of 

beans.)     Occasional  issues  (extra)  of  molasses  are  made — two 

quarts  to  one  hundred  rations — and  of  dried  apples  of  from  one 

to  one  and  a  half  bushels  to  one  hundred  rations.  Troops  at 
sea  are  recommended  to  draw  rue  and  an  e\tra  issue  of 
molasses  in  lieu  of  bean-.  When  anti-scorbutics  arc  issued, 
the  medical  officer  will  certify  the  necessity,  and  the  circum- 

stances  which  cause  it,  upon   the  abstract  of  extra  issues. 


A  DDK N  I )  A 


I.  .(Hirers  of  the  Medical  Department,  by  virtue  of  their 
comauosions,  commaad  enlisted  men. 

Medical  officers  will  not  give  certificates  of  disability  for  dis- 
charge from  the  service,  on  account  of  single  Reducible  Hernia, 
when  the  patient  is  under  85  years  of  age. 

2*. The  Medical  Director  and  the  Medical  Purveyor  of  a 
Military  Department  are  each  allowed  one  room  as  an  office, 
and  fuel  from  the  1st  of  October  to  the  30th  of  April,  at  the 
rate  of  one  curd  of  wood  per  month  Cor  each  office. 

8;.. Ambulances  are  not  to  be  used  for  any  other  than  the 
specific  purpose  for  which  they  are  designed,  viz;  the  trans- 
portation of  the  sick  and  wounded. 

I.. Hospital  laundresses  will  be  paid  eight  dollars  per  month, 
liv  the  Quartermaster  Department,  on  the  hospital  muster  rolls, 

and  will  be  allowed  one  ration  per  diem. 

."< .  .A  regiment,  in  the  Held,  is  allowed  two  four-wheeled  and 
me  number  of •  two-wheeled  ambulances;  and  one  wagon 
for  the  transportation  of  hospital  supplies. 

6.. Hospital  tents,  having  oa  one  end  a  lapel,  so  as  to  admit 
of  two  or  more   tents  being  joined    and  thrown   into   one  with 


APPENDIX. 


47«J 


a  continuous  covering  or  roof,  will  be  made  of  these  dimen- 
sions : 

Length,  14  feet;  width,  15  feet;  height  (centre),  11  feet, 
with  a  wall  -ih  feet,  and  a  "fly"  of  appropriate  size.  The 
ridge  pole  will  be  made  in  two  sections,  measuring  1  I  feet 
when    joined. 

This  tent  will  accommodate  from  eight  to  ten  patients  com- 
fortably. 

Tlie  following  allowance  of  tents  for  the  sick,  their  attend- 
ants, and  hospital  supplies  will  be  issued  on  requisitions  on  the 
Quartermaster  Department : 


COMMANDS. 

I 

HOSPITAL  1       SIBLEY 
TENTS.             TENTS. 

COMMON 
TENTS. 

For  one  companv 

For  three  companies  ..... 

For  five              "           

For  seven           "           

For  ten               "            

1 
2 
2 
3 

1 
1 
1 
1 
1 

1 
1 

1 

1 

1 
?• 

7.. The  following  Blanks  will  be  issued  from  the  Surgeon 
General's  office  : 

Monthly  Reports  of  Sick  and  Wounded. 

Quarterly  Reports  of  Sick  and  Wounded. 

Consolidated  Monthly  Reports  of  Sick  and  Wounded  (for 
Medical   Directors). 

Returns  of  Medical  Officers  (for  Medical  Directors). 

Returns  of  Medical  and  Hospital  Property. 

Abstracts  of  Medical  and  Hospital  Property  (for  Medical 
Purveyors). 

Requisitions  for  Medical  and  Hospital  Supplier 

Medical   Purveyors  will  be  allowed  to  print  only  their  blank- 
Invoices  and    Receipts.     Other  medical  officers  will  not   have 
any    blanks   printed,  except    by    special   authority   from  th 
geon-jGreneral. 

Certificates  of  Disability  for  Discharge  from  the^ervice,  and 
Hospital  Muster  Rolls,  are  furnished  from  the  Adjutant  and 
Inspect  or-Cieneral's  office. 


WO  APPENDIX. 

x.  .Official  letters  addressed  to  the  Surgeon-General,  by  medi- 
cal ottcera  of  the  army,  will  be  written  <>m  letter  paper  (quarts 
post)  whenever  practicable,  am)  not  on  not*/  or  foolscap  paper. 
The  letter  must  be  folded  i"  1 1 1 r*-« ■  equal  folds',  parallel  with  the 
writing,  and  t*n«  1. >r--. -.  1  across  that  fold  which  corresponds  with 
the  top  of  the  sheet,  thus : 


[Name  and  rank  nf  writer.] 


[Poal  Of  station  and  data  of  letter.] 


[Analysis  If  (  ontente,  ] 


SMJ153U 


•S'OSU^) 


■Bq»«9Q 


•sas«o 


*m«aa 


'B9&BQ 


•blHB9(J 


•S88«0 


■Bq^voa 


•S9SV3 


GO 

o 

< 

< 

w 

.J 

CO 

y 

•-" 

-i—  -  - 

B'53t 
=  -  r  * 
=  -.-■= 


beg  -  -  n-r-c-c^:  v. 

-     S    —    t   *-     •      ■-    1, .  ..     0 


is  ;i:r- 


<—  - 


i     '     -.   ,ti  ^.™~        •_'  T!   H   .-*   i—  —         —   —    -    "     j 


:Ci::;;-:;: 


g 


••• 


** 


* 


APPENDIX. 


481 


Form    1 — Contihued. 
DISCHARGES  01  BUlQBOmS  CERTIF 19  1TE,   A.ND  DEATHS. 


N  \MF. 

Rnnk. 

e 
— 

1 

Date  of  ih- 

Date  of 

sin  name. 

Christian 
aame. 

1 

0 

service. 

death, 

• 

« 

REMARK: 


•  hi  Surgeon's  certificate,  and  deaths  occurring   .uiMiig  those 
of  the  command  not  on  ?-i<  K  report,  will  b  I.  bul  separate  1  I 

others   b>    a  double  line  drawn  screes  i!m.  page.    TIip  remarks  will  in  i 
b I > •  ■  < - i l  \   ihe  manner  in  which  tin  natod.  when  it  is  known 

In  every  case  r.f  the  ileatli  "I  an  officer,  whethei  "ii  duty  "i  ii"t.  a  special  report 
i*  t,.  he  ina  ie  to  the  Surgeon -General 

41 


182 


AI'l'KMUX. 
Form    1 — Continued. 

iltNT. 


ELEPOfiT  OF  sick   ANH  WOUNDED. 


F'i|{  THK 


QitmrU  r  ending 

St <it ion  : 


186  . 


c.iMMAND. 


1 1  1 1 .  ■  I  \l  I .  N  I  B  - 


(  OH  Pi  NUM. 


APPENDIX. 


483 


00 


-'  V 


?s 


Btj-5 


.J    »> 


Remarks . 

■ 

a. 
o 
s 

<  > 

=  s 

gg 

£ 

< 
■ 

M 

f- 
c 

H 
I 

- 

« 

* 

• 

0 
7. 

5  £  i-  S  S  2  « 

■    ---'-;-  6 

S    SbuS»jj  — 

'.     ~  -  =  .1  i  -  - 

s.  8  c  g  a  a  = 

_£  =  -=^  I. 

!Oh  joe  g 


<  s ~  - 


r    :    - 
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I*M  Al'l'ENDIX. 

I"  -.KM      1    3  . 

akmv  <>r  tiii:  .  "\n  DM  \ti:  R  \  i  M 

[('<.«!  .if  Arm».] 

DisabUUif  far  Discharge. 

A   I'..  ..f  Captain  —    — *i  coanpaarjr,  (     ).  of  tin-  — —  rcja- 
iiH -in  nt'  Confederate  States ,  was  enlisted  by , 


regiment  of .  at  ■ — —.on  the day  of- 


yearaj    he   vras  born   in ,  in  the   State  .>t' 

—  yean  of  age; fret indie*  hfgh, 

complexion, e\e-. liair.  ami  by  occupation,  wlien  en- 
listed,  ■.     During  the  las(  two  months,  said  tieku&r  hanbeen 

unlit  for  duty days. 

[The  company  commander  will  hen-  a. 1.1  a  statement  >'t'  all 
tlie  facta  known  to  liitn  ejouteiuiug  'lie  disease  or  wound,  or 
cause  nt  disability  "t"  the  soldier;  the  time,  place,  manner;  ami 
all  tin-  circumstances  under  which  tit*-  injury  occurred,  or  disease 
originated  or  appeared  :  the  duty.  <u-  service,  or  situation  ojf  the 
soldier  at  the  tune  the  injury  wan  received  or  disease  contracted, 
or  supposed  to  be  contracted  ;  and  whatever  facts  may  aid  a 
judgment  as  to  t  It*-  cause,  immediate  or  remote,  of  the  disability 
and  the  circumstances  attending  it.] 

(    I »,  < 'ommanding  <  'ompttjy. 

[When  t lie  fact.*  are  not  known  to  tlie  company  commander, 
the  certificate  of  any  officer,  or  affidavit  of  other  person  having 
inch  knowledge,  will  be  appended.] 

I  .  i  Kin  v  that    I    have  ran  l'iill\   examined  the  said  of 

Captain 's  company,  and   find  him  incapable  of  perfbrm- 

in;_r  the  duties  of  a  soldier  because  of  [  here  describe  particularly 
the  disability,  wound,  or  disease ;  the  extent  to  which  it  deprives 
him  of  the  use  of  any  limb  or  faculty,  or  affects  hi^  health, 
strength,  activity,  constitution,  or  capacity  to  labor  or  earn  his 
subsistence].  The  Surgeon  will  add.  from  bis  knowledge  of  the 
facts  and  circumstances,  and  from  the  evidence  in  fee  case,  his 
professional  opim i  the  cause  or  origin  of  the  disability. 

K  F.  Sttryt  on. 
I 1. 1  rui  mi.-. 

1.  Winn  a  prtbmblt  east  Cm  pawtiwi,  tpecitX  cam  sunt  bstalMa  tosttM 

iIh-  ./.  ./I-. i  of  (Usability. 
2   The  pluce  wh>'if  the  tolditr  decuos  to  W  atidr'trnl  may  hf  Uoi  o  iuld^  1 
T'tm-  Chunty-  fit<it.- — 


APPENDIX. 


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API'KM.IX. 


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Remain  in1-'. 

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1 

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■>(>)!«   U05Jt.'X 

Remaining  at 
last  report. 

■saojjitnl i  uj 

•|i:inl>oq  nj 

L*Y. 

■ 
< 

APPENDIX.  497 

Form    16. 

CONTRACT  WITH  A  PRIVATE  PHYSIC! AN. 

This  contract,  entered  into  this  day  of ,   IS — , 

at  ,   State  of .  between  ;  of  the    C.  S. 

Army,  and    Dr.    — .  of  — .   in  the    State  of  , 

witnesseth,  that  for  the  consideration  hereafter  mentioned,  the 

said  Dr.  — —  promises  and  agrees  to  perforin  the  duties  of 

a  medical  officer,  agreeably  to  the  Aran   Herniations,  at 

(and  to  furnish  the  necessary  medicines).     And  the  said  

promises  and  agrees,  oh  behalf  of  die  Confederate  Stales, 

to  pay,  or  cause  to  be  paid,  to  the  said   Dr. .  the  sum 

of dollars  for  each  and  every  month  he  shall  continue  to 

perform  the  services  above  stated,  which  shall  be  his  full  eom- 
pens at  ion.  and  in  lieu  of  all  allowances  and  emoluments  whatso- 
ever (excCpt  thai  /<»•  medicines  furnished,  which  shall  he  at  the 

rate  of per  cent,  on  his  monthly  pay,  to  be  deU  rmint  d  by 

tin  Sun;e>>it-<li  nrral).  This  contract  to  continue  till  determined 
by  the  said  doctor,  or  the  commanding  ollieer  for  the  time  l>eing, 
or  the  Surgeon-General. 

[SKAL.] 

Signed,  sealed,  and  delivered,  > 

in  presence  ot  ^ 

[  >l   AL.] 


I    certifV  that   the   number  of  persons  entitled   in  medical  at- 
tendance, agreeably  bo  regulation*,  at  is  ,  and  that 

no  competent  physician  can  be  obtained  at  a  lower  rate. 

.  ( 'iiiiiiiKiiidiin:  (Jjficer. 

42 


498  APPENDIX. 


Form    17. 
FORM  OF    A  MEDICAL  CERTIFICATE.. 

FOR    LEAVE    OF    ABSENCE. 
of  the  regiment  of ,  having  applied  for 


a  certificate  on  which  to  ground  an  application  for  leave  of  ab- 
sence, I  do  hereby  certify  that  I  have  carefully  examined  this 

officer,  and  find  that .      [Here  the  nature  of  the  disease, 

wound,  or  disability,  is  to  be  fully  stated,  and  the  period  during 
which  the  officer  has  suffered  under  its  effect*.]  And  that,  in 
consequence  thereof,  he  is,  in  my  opinion,  unfit  for  duly.  I 
further  declare  my  belief  that  he  will  not  be  able  to  resume  his 

duties  in  a  period  less  than  .     [Here  state,  candidly  and 

explicitly,  the.  opinion  as  to  the  period  which  will  probably  elapse 
before  the  officer  will  be  able  to  resume  his  duties.  When  there 
is  no  reason  to  expect  a  recovery,  or  when  the  prospect  of  recov- 
ery is  distant  and  uncertain,  it  must  be  so  stated.] 

Dated ,  this day  of . 


Signature  of  the  ) 
Medical  olficer.  j 


APPENDIX. 


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APPENDIX. 


Form    19 


.1    Montlily  Statement  of  the  Hi-spital  Fund  at 
month  of ,   186 — . 


-,  for    thf 


1>K. 

To  balance  due  hospital  last  month,         -        -  8  0  00 

1,532  rations,  being  whole  amount  due  this  month, 

at  9j  cents  per  ration, 145  5-4 


Ck. 


1881  ri>. 


By  the  following  pro\ -isions.  at  contract  ptiotHJ 

js.".}     lbs.  of  ])ork,  at  6  fonts  per  pound, 
690      His.  of  fresh  beef,  at  4c.  per  pound, 
l.iii •_',",;  lb*  of  (lour,  at  2  cent-;  per  pound, 
10      lbs,  ef  hard  bread,  ai  8£c.  per  11>. 

JO         Iba  of  rice,  at   6  cents  per  pound, 

56  His.  of  coffee,  at  9  eta  per  pound, 
193  J  g  lbs.  of  sugar,  at  8  eta  per  pound, 
17£  qrts.  of  vinegar,  at  5c.  per  quart, 
15,'';  Iba  of  candles,  at  12c.  per  pound, 
6l4  Iba  of  soap,  at  6  cents  per  pound. 
16$  qrts.  of  salt,  at  3  cents  per  quart, 
12       galls,  molasses,  at  88c.  per  gallon. 


PURCHASED. 


2  pra  of  chickens,  at  87Ac  per 

pair,          -         -         -         -  SI    75 

■1   qrts.  of  milk,  ai   7c.  per  quart,  0   28 

:f  do/.,  oranges,  at  25c.  per  doz.  (|  76 

Total  expended,        -  - 

Balance  due  this  month,  - 


Sill  is-,1 


i   78 


114    96? 


$30  57.; 


[Date] 


Surgeon. 


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—  e-i  .-.  —    -    -  i  -  cc  cr  o  o  o 

HCC 

Appendix  K<>.  J. 


MEMORANDUM 

FOR    THE 

INFORMATION  OF  MEDICAL  OFFICERS 

IX   TIIK    KXCI.ISIl    ARMY, 
o\    TAKING    rrn:    FIELD  FOR  active    SKiivici:. 


1.  .The  ambulance  equipment  for  one  division  of  tlie  army, 
consisting  of  two  brigades  of  tittle  battalions  cadi — tlic  battal- 
ion- 1  »inur  600  strong — Tumid  consist  of  two  large  stone  wagons, 

to  be  under  the  care  of  a  purveyor's  clerk,  at  the  head-quarters 
of  tlie  division.  TblMS  wagons  to  contain  a  reserve  supply  of 
medicines,  materials,  medical  comforts, tents  and  beddrhg.  Each 
battalion  surgeon  should  have  a  pack-horse  for  the  conveyance 
of  his  instruincnts.  a  few  medical  comforts  for  immediate  Me, 
such  as  a  bottle  of  brandy,  half  pound  of  tea.  one  pound  of  su- 
gar, and  four  ounce-  of  aiwwruet,  a  few  tin-  of  essence  of  beef, 
sonic  medicines,  and  a  supply  of  surgical  materials  agreeably  to 
tlie  printed  scale  laid  down  in  the  regulations.  A  spring  wagon 
should  also  be  attached  to  each  battalion  tor  the  removal  of  the 
wounded  off  the  field,  and  for  the  conveyance  of  the  hospital 
■'-.   A  and   1'..  with  twelvi  bedding,   ten   CBtbVSM 

bearers,    and    the    hospital    marquee    on    the    line    of  man  h  ;  or. 


"»<M  MI'IM-IX. 

when  the  spring  wagons  are  either  small,  or  required  for  the 
conveyance  of  rick  and  wounded,  a  reserve  wagon  might  be 
attached  to  each  brigade  Cor  the  carriage  of  these  articles. 

Canvas  bearers  with  long  poles,  and  shoulder  straps,  in  pro- 
portion of  twe  to  every  hundred  men,  "ill  also  be  required. 

2.  Before  a  division  takes  the  field,  tin*  principal  medical 
officer  should  satisfy  himself  bj  personal  inspection,  thai  the 
equipment  <>i  Burgeons  of  regime  m«  is  complete  in  every  respect, 
and  it  would  be  a  neceasar}  precaution  \<<v  him  to  see  the  pack 
horses  loaded  in  Ids  presence,  as  by  that  means  be  would 
tain  that  ti"  straps,  buckles,  of  cords  were  wanting: 

3.. When  an  action  with  the  enemy  seems  inevitable,  the 
surgeon  of  each  regiment  "ill  make  arrangements  lor  the  re- 
moval of  tin-  wounded  of  Ids  corps  from  the  field,  and  it  would 
be  desirable  for  him  to  give  some  instructions  to  the  bandsmen, 
and  others  employed  in  that  duty,  how  to  apply  a  field  tourni- 
quet, to  restrain  dangerous  hemorrhage  until  the  assistance  of 
the  medical  officer  on  the  field  '-an  be  obtained;  and  for  this 
purpose  a  tourniquet  should  !»•  given  to  each  part}  of  bearers. 
The  bearers  should  also,  each  of  them,  carrj  a  canteen  full  of 

water. 

4.  .While  the  troops  are  advancing,  the  medical  officers  will 
follow  with  the  spring  wagons  and  bearers,  and  any  other  conr 
veyance  that  is  available;  but  when  they  deploy,  or  form  fox 
action,  ail.  except  one  medical  officer  per  regiment,  "ill  move  a 
-holt  distanrr  to  tin-  nar.  out  of  musket  range,  and  will  prepare 
for  adbrding  aid  to  the  wounded,  and  performing  such  primary 
operations  as  max  be  deemed  absolutely  necessary.  For  this 
purpose  the  Burgical  panniers  must  be  brought  up,  and  instru- 
ments, ligatures,  dressings, and  cordials  (brand}  )  got  ready,  and, 
above  all  things,  an  abundant  supply  of  water  provided,  for  the 
safe  and  easj  conveyance  of  which,  the  leather  bags,  or  skii^, 
formerly   recommended,  would  !'<■  found  most  convenient. 

Dr.  Hall  takes  this  opportunity  of  cautioning  medical  officers 
against  tin-  use  of  chloroform,  in  the  severe  shock  of  serious 
gunshot  wound-,  a-  h<-  thinks  h-w  will  survive  where  it  i-  ased. 
But,  as  public  opinion,  founded,  perhaps,  on  mistaken  philan- 
thropy, he  kno".-.  i-  against  him,  In-  can onij  caution  medical 


officers,  and  entreat   they  will  narrowly    watch    its  effects,  for 
however  barbarous  it  may  appear,  the  smart  of  the  knife  is 
powerful  stimulant,  ami   i'   is  much  better  to   hear  a  man  bawl 
lustily  see  him  sink  silently  into  the  gn 

5.. One    medical    d.i   ■  h     regiment,    generally    1 1 1- - 

junior  assistant  surgeon,  should  follow  the  troops  within   nm- 
range.  so  as  to  be  ;■(   hand  M  dheek   any  alarming   hemorrhage, 
and  to  expedite  the  removal  of  tin'  wounded  off  tin'  fiehl  to  the 
rear:   ami  for  this  purpose   the   bearers  should    he   placed   under 
Iris  orders,  and  the  regimental  spring  wagon  be  lo  stationed  as 

to  be  wilhin    eas\    r--;i'-li.  lo   eomey   t  in  in   to   where  t he  surgeon 

and  his  aarintfcnla  have  established  themselves.  The  field-assist- 
ant should  cany  with  him.  in  his  haversack.  his  po<  Ifiel  case  of 
instrument-,  with  a  few  ligatures  ready  cut.  two  field  tourni- 
quets, some  lint,  and  two  or  three  bandages:  and  he  should  be 
accompanied  bj  three  m  n:  one  with  a  knapsack,  or  haversack, 
containing  one  pint  boitle  ot'  brandy,  or  some  other  stimulant. 
twenty-four  bandage?,  halt' a  pound  of  lint,  three  sponges,  six 
long  and  six  short  solid  splints,  two  old  sheets  PU4  into  quarters 
before  starting,  lor  the  pumose  of  rolling  fractured  limbs  in.  and 
so  pre  venting  them  from  sustaining  further  injury  on  the  men's 
remoxal   from  tic   field.     Thi-  r»  nmpiished  by   placing 

the  old  limn  under  1 1 1 « ■  liml),  and  rolling  the  s] dint  up  in  it  from 
the   outer   vi\'j[r.  ami    roiling  toward  the  limb   on    each   side,  and 

then  securing  the  whole  vita  two  or  three  band* of  tape.     In 

this  way   1  >r.  Hall  thinks  medical  officers  will  find  f'hc\   can  tem- 
porarily   secure    fractured  limb-   better  and   oracii  more  el 
dilioiish    than  In   any  olher  manner.      T<he  Ortferly  should   ha\. 
in    his   h;ivers;i.  k.  in    addiiion   to   ihe    above    articiea,   B    | 
tape,  some  pins,  and  two  or  three  rolls  of  tow.      He  should  earn 
a  i  anieeii.  eiiher   of  wood    pr   india-rubl>er,  full    of  water,  and  a 

drinking  eup.      I       ft    ond  man  should  pan  k  boarai 

■  ;.h  shoulder  straps,  and.  like  tlx-  rantee, 

full  of  water.  Z«e  third  nian.  1  think,  should  be  armed,  to  pro- 
tect the  patty  against  and  marauders,  and.  like  bis 
fellows,  carry  a  canteen  full  of  water.     The  afrnnd  abstain  - 

•i  should  receive  the  wounded  from  the  i  «re- 

lailv  placed  in  »«.  and  lie 


5U6  \1  I  K.NDIX 

wapon  to  whore  the   surpeon  and  third   assistant   are   stationed, 
ready  to  afford  them  the  surgical  aid  they  may  require.     For 

rvice  the  second  assistant  surpeon  should  be  accompanied 
by  two  men  to  assist  in  placing  the  men  carefully  in  the  wagoa; 
these  men  should  accompany  the  wapon,  and  assist  in  like  man- 
ner in  takinp  tlie  wounded  out.  These  men  should  likewise 
carry  canteens  full  of  water,  and  then-  should  be  a  .-kin  of  water 
a-  a  reserve,  in  the  wapon,  with  a  drinkinp  cii]>. 

6.  .The  site  selected  by  the  staff-surpeon  of  brigade  for  the 
reception  of  the  wounded  from  the  held  should  be  as  sheltered 
M  pOMiUe;  and  it'  not  easily  distinguished,  a  flap  should  be  put 
ii|>  |  and  it'  any  houses  be  near,  calculated  for  the  reception  of 
wounded  men.  the\  should  lie  taken  posnMIM  of  at  MM,  and 
an  aliundant  supjdy  of  water,  and.  if  possible,  straw  provided. 

7.. Should  the  action  prove  decisive,  tents  can  lie  pitched 
lor  the  temporary  accommodation  of  the  wounded ;  but  should 
the  army  advance,  the  surgeon,  and  one  assistant,  at  least,  should 
accompany  their  repiments,  leavinp  one  or  two  assistants,  accord- 
ing to  the  number  of  wounded,  to  aid  the  divisional  stall',  who 
will  piteh  the  reserve  marquees,  and  make  all  necessary  prepar- 
ation for  the  comfort  and  accommodation  of  the  wounded  by 
having  tea.  broth,  or  essence  of  beef  (which  is  readilv  made  into 
broth  by  adding  hot  water),  wine,  and  braud\,  etc..  ready. 
Should  (he  army  unfortunately  meet  with  a  reverse,  all  avail- 
able transport  nm-l  lie  pressed  for  the  removal  of  the  wounded 
to  the  rear,  and  they  must  he  sent  off  as  speedily  as  possible  ; 
but  neither  here,  nor  on  the  field  of  battle,  should  any  one  be 
carried  wdiosc  hurts  are  so  slight  as  to  admit  of  his  walking. 
Nor  should  nommanding-ofticcrs  of  regiments,  when  wounded, 
be  allowed  to  take  medical  officers  of  their  own  corps  to  the 
rear  with  them,  or  officers  of  any  grade  be  permitted  to  appro- 
priate the  sprinir  wapons  for  the  special  coin  e\  anee  of  thein- 
selves  and  their  lupgage  :  and  positive  orders  should  be  uiven  to 
pn\cnl  bandsmen,  drummers,  or  pioneers,  specially  told  olf  to 
assist  the  wounded,  from  beinp  left  in  charge  of  officers' horses 
and  effects. 

8.. Should  the  army  have  to  effect  a  landinp  on  an  enemy's 
coast,   with   an  opposing   force  to  meet  it,  the  men  should  cat  a 


APPENDIX. 


5(fi 


pond  meal  before  leaving  the  ships,  and  should  cook  whatever 
provisions  it  is  necessary  to  serve  oat  to  them  before  the  start. 

Pork  is  better  than  beet'  tor  tin's  purpose,  as  i(  warms  up  more 
readily  with  any  vegetable  the  men  may  find  on  shore.  The 
medical  officers  should  land  with  the  last  boats  of  their  regi- 
ments, and  should  carry  with  them  their  haversacks,  dressings, 
and  canvas  bearers,  if  the  landing  be  opposed,  so  as  to  be  able 
to  bring  the  wounded  at  once  to  (he  boats  for  conveyance  to  the 
ships  set  apart  for  their  reception;  care  should  be  taken  that 
each  boat  employed  in  this  service  contains  a  supply  of  water 
and  a  drinking-horn. 

!>..  Should  a  landing  be  effected,  and  any  horses  lie  disem- 
barked, the  surgeon's  pack-horse  and  panniers  should  be  amongst 
the   tnt. 

lo.  ,Afl  soon  after  an  action  as  possible,  medical  officers  in 
charge  of  corps  will  make  out  and  transmit  to  the  Inspector- 
General  of  hospitals,  for  the  information  of  the  General  com- 
msnding-in-chief,  returns  of  casualties  made  out  agreeably  to 
the  following  form  : 


Return  of  Killed  and   Wounded  in  the 

of  


Regiment,  in  ihr   action 


Danger 
ously. 


Total 


Ij    \\  ounded. 


i  ifficers. 

N  OS-com- 
missioned 
officers 

:•  in  I    pi  i 


i  officers  Uill- 
i'il  Mid  wounded  to 
be  u»8(  rted  h 


48* 


Atpendix   No.   3. 


DIRECTIONS 


COOKING  BY  TROOPS  IN  CAMP  AND  HOSPITAL. 

PRSPARBB    ruR    Till'.    AIDIV    A\l>    PUBLISHED    BY    o  111)  Kit    <>K    1  !!  B 
SI  RQRON-QBNERAL. 


DIRECTIONS  FOR  COOKING   IN   CAMP. 


COFFEE    FOB    ONE    HUNDRED    MEN,  ONH    TINT    EACH. 

Put  12  gallons  water  into  a  suitable  vessel  (or  divide  if  ne- 
cessary) on  the  fire  :   when  boiling,  add   '■'>  lbs.  ground  coffee  : 

mix  well  will:  a  spoon;  leave  on  the  lire  a  few  minutes  longer; 
take  it  oil*,  and  pour  in  I  a  gallon  cold  water:  let  it  stand  till 
tin'  dregs  subside,  sa]  from  5  to  1 0  minutes ;  then  pour  off,  and 
add  6  lbs.  sugar.     IT  milk  is  used,  put  in  12  pints,  and  diminish 

tin'  water  by  that  amount. 

FRESH    BEEF    SOUP    FOB    ONB    HUNDRED    MEN. 

Take  7")  lbs.  beef ;  cui  into  pieces  of  about  j  lb.  each;  !•"» 
gallons  water:  8  lbs.  mixed  vegetables;  10  -mall  table-spoonfuls 
sail:  2  small  table-spoonfuls  ground  peppery  some  cold  bread, 

crackers,  or  .'!  lbs.  rice,  to  thicken  :  place  on  the  lire  ;  let  il  come 
to  a  boil  ;   then  simmer  tor  .'!  hours.      Skim  off  the  t'at  and 


APPENDIX. 


BOTERS    -  i  '  w     !  "i:    OKE    flXJNDRl  i>    Ml  N. 

Cut  50  lbs.  fresh  beef  in  pieces  of  about  j  lb.  each,  and  with 
water  put  int<>  the  boiler;  add  l"  table-spoonfuls  of 
Bait,  iwu  of  pepper,  7  lbs.  onions,  cut  in  Blices,  and  20  lbs.  | 
toes,  peeled  and  sliced;  Btir  well,  and  let  it  boil  for  20  or  SO 
minutes;  then  add  I  1  lbs.  Hour,  previously  mixed  with  water; 
mix  well  together,  and  with  a  moderate  heat  simmer  for  about 
l'  hours.  Mutton,  veal  or  pork  can  be  Btewed  in  a  Bunilar  man- 
ner, l>ut  will  take  half  an  bour  less  cooking.  A  pound  of  rice, 
or  plain  dumplings,  may  be  added  with  great  advantage. 

i     DUMPLINGS. 

Take  10  lbs.  flour,  15  tea-spoonfuls  of  salt,  7  of  ground  pep- 
per, 7  lbs.  chopped  fat  pork  or  suet,  6  pints  water;  mi  well 
together:  divide  into  about  L50  pieces;  which  roll  in  flour,  and 
boil  with  meat  for  20  or  80  minutes,  [f  do  fat  or  suel  can  lie 
obtained,  take  the  same  ingredients,  adding  a  little  more  water, 
and  boil  about  10  minutes.     v  rve  with  the  meat. 

Place  your  pan  on  the  fire  for  a  minute  or  so;  wipe  it  clean  ; 

when  the    pan    is   hot.  put    in  either  tat   or  butter  (fa!   from  salt 

meat  is  preferable)  ;  then  add  the  meat  you  are  going  to  c 

turn    it    several    i  inn  >   to  have   it 

pound  a  small  tea-spoonful  of  salt  and  a  quarter  of  pepper.     A 

few  onions   in  the  remaining  b  the  addition  of  a  little 

flour,  a  quarter  pint  of  water,  two  table-s] nfuls  of  vinegar,  or 

a  few  (diopped  pickles,  will  be  very  relishing. 

TO    COOK    BA1  i     in  i  i     OB    l'OKK. 

Put   the  meat,  cut  in   pieces  of  from  S  to  i  lbs.,  to  soak  the 
night  before  ;  in  the  morning,  wash  in  fresh  water,  and  squi 
well  with  the  handi  to  ct  the  salt  ;  after  which,  put  in  your 

kettle,  with  a  pint  of  water  to  each  pound,  and  boil  from  two  to 
three  hours. 


APPKNTMX. 


511 


SALT    BEEF    OR    PORE,  WITH    MASHED    BEANS,  FOB    ONE    HUN- 
DRED   MEN. 

Put  in  two  vessels  87£  His.  meal  each  ;  divide  24  lbs.  bean*  in 
four  pudding-cloths,  loosely  tied;   putting  to  boil  ;it   tin 
time  as  your  meat,  in  sufficient  water  ;  let  all  boil  gently  for  two 
hours;  take  oul  the  meal  and  beans;  put  all  t lie  meat  into  one 
boiler,  and  remove  the  liquor  from  the  other;  into  which  turn 
out  the  beans;   add  to  them  two  tea-spoonfuls  of  peppi 
pound  of  fat,  and  with  the  wooden  spatula  mash  the  beans 
serve  with  the  meat.     Six  sliced  onions,  tried  and  added,  im- 
proves the  dish. 

[Note.— In  cooking  all  kinds  of  meat,  he  careful  to  preserve 
the  grease,  which  can  he  easily  dune  by  putting  the  liquor  in 
which  it  is  boiled  by  till  il  cools:  then  skim  oil'  and  place  in  a 
(dean  covered  vessel.  It  is  an  excellent  substitute  for  butter; 
is  useful  lor  cooking  purposes,  and  will  burn  in  a  common  lamp 
or  tin  plate,  with  a  piece  of  old  cotton  twisted  up  for  a  wick.] 


DIRECTIONS  FOR  COOKING  TN  HOSPITAL. 


MUTTON    STEWED,   AM)    SOUP    FOR    ONE    R  I  U'V. 

Put  in  a  convenient  sized  \  esse!  16  gallons  water,  60  lbs.  meat. 
\2  lbs.  plain  mixed  vegetables,  9  lbs.  pearl  barley  or  rice 

ten),  H  lbs.  salt,  i .}-  lbs.  flour,  I  ••     Ptrt  all  tlm 

ingredients,  except  the  flour,  into  th  ■   if  on  tfl 

and  when  beginning  to  boil  diminish  the  heat,  and  si 
lv  for  two  boars  and  a  hah':  take  the  meal  out  and  keep  warm  ; 
add  to  the  soup  your  flour,  which   you    have   mixed  with  i 
to  form  a  light  batter;  stir  well  together  with  a 
spoon:  boil  another  half   hour;  skim  off  the  fat,  ami  serve  the 
meat  and  soup  separate.     The  soup  should  be  stored  occasion- 
ally while  making,  to  prevent  burning  or  sticking. 


312  Al'l'K.MUX. 

i;i  i  I     BOOT.* 

Proceed  tin-  same  ;i>  for  mutton,  only  leave  the  meat  in  till 
serving,  as  it  takes  longer  to  cook  thaa  mutton.  Xhe  pieces  are 
not  to  ba  above  i  oc  5  ll>s.  weight  each. 

r.i  i  i    1 1  \.  bi  i  ii  n  i  a. 

Cut  three  pounds  lean  beef  into  pieces  the  size  of  walnuts, 
ami  break  up  the  bones  (it*  any) ;  put  it  into  a  convenient  Bused 
kettle,  with  J  11).  mixed  vegetables  (onion-;,  celery,  turnips,  car- 
rots, or  one  or  two  of  these  it'  all  arc  not  to  be  obtained),  1  OB. 
salt,  a  little  pepper,  2  oz.  butter,  .',  pint  of  water.  Set  ii  on  a 
sharp  fire  for  15  minutes.  Btirring  occasionally,  till  it  tonus  a 
rather  thick  gravy  at  the  bottom,  but  not  brown;  then  add  7 
pints  of  hot  water ;  simmer  gently  for  an  hour.  Skim  off  all 
the  fat,  strain  through  a  sieve  and  serve. 

THICK     BEEF    TEA. 
Dissolve  a  tea-spoonful  of  arrowroot    in   a  gill   of  water,  and 

pour  it  into  the  beef  tea  twenty  minute-;  before  passing  through 
tin-  sieve,  or  add  ^  oz.  gelatine  to  the  above  quantity  of  beef  tea, 
w  ben  cooking. 

Mutton  and  veal  will  make  good  tea  hy  proceeding  the  same 
as  above. 

KSSKXCK    OF    UKKF. 

Take  l  lb. lean  beef;  cut  fine;  put  it  into  a  porter  bottle  with 
a  lea- cup  of  water,  I  tea-spoonful  of  Bait,  a  little  pepper,  and  •' 

grains  allspice;  cork  loosely,  and  place  in  a  sauce-pan  of  cold 
water;   then  with  a  gentle  Ileal   let   il  .-iniiner  till  sullicient  cpian- 

tii\  of  the  essence  is  obtained.     Serve  either  warm  or  cold. 

CHICKEN    BROTH. 

Put    in   a  stew-pan  a  fowl.  ."!  pints  of  water.  2  tea-spoonfuls  of 

rice,  l  of  salt,  a  little  pepper,  and  a  small  onion,  or  2  oz.  of  mixed 

,i,  Issued  to  tin-  hospitals  wbm  *n]i|iii.-<  an-  difficult  to  ba 
obtained. 


APPKNMX. 

vegetables ;  boil  the  whole  gently  for  one  hour  (if  an  aid  fowl 
simmer  for  two  hours,  adding  one  pint  more  water}.  Skim  off 
the  fat  and  Berve. 

A  light  mutton  broth  may  be  made  in  the  same  way,  taking 
1£  lbs.  mutton — meek  if  convenient. 

PLAIN    r.oll.KD    KICK. 

Put  two  quarts  water  in  a  stew-pan,  with  a  iea-sp<-onfnl  of 
salt:  when  boiling,  add  to  it  ^  lb.  rice,  well  washed:  boil  for 
ten  minutes:  drain  oil'  the  water,  and  slightly  grease  the  pan 
with  butter;  put  the  rice  back  and  let  it  swell  slowly  lor  about 

twenty  minute-,  near  the  lire.      Each  grain  will    ihen    swell    up. 

and  be  well  separated.  Flavor  with  nutmeg  or  cinnamon,  and 
sweeten  to  i 

-  \<<>    .U.i.LY. 

Put  in  a  pan,  with  :;  pints  water.  :;  oz.  >ago.  H  03.  sugar,  half 
a  lemon  peel  cut  very  thin,  ±  tea-spoonlul  of  around  einnanion, 
or  a  small  stick  of  the  same,  and  a  little  salt  ;  boil  about  fifteen 
minutes,  stirring  constantly;  then  add  a  little  port,  shorn  or 
madeira  wine,  as  the  ease  will  admit 

AKKow-KooT   milk. 

Put  in  a  pan  4  oz.  arrow-root,  '■'<  BA  SOgBT,  the  peel  of  half  a 
lemon.  ]  tea-spoonful  of  salt,  •_' ',  pints  of  milk;  Be!  it  on  the  lire: 
stir  gently:   boil  for  ten  minute-,  and  -rrve. 

If  no  lemons  af€  at  hand,  a  little  essence  of  any  kind  will  do. 

When  Bhorl  o£  milk,  use  half  waters-half  an  (inner  of  batter 
i-  an  improvement. 

ARBOW-ROOT    WATKR. 

Put  in  a  pan  3  oz.  arrow-root.  2  oz.  white  sugar,  the  peel  of  a, 
lemon,  {  tea-spoonful  of  -alt.  and  t  pints  water;  mix  well,  set 
on  the  fire,  and  boil  for  ten  minute*      Serve  h<>t  or  cold. 

Kii  i     w  \  1 1  i:. 

Put  7  pints  water  to  boil ;  aid  2  <</■  rice,  washed,  2^>z.  - 
the  pe.d  of  two-thirds  of  a  lemon,  boil  gently  Tnr  thrce-qu 


•'>''4  \1-1T.MU  \. 

of  an  lionr.  or  ti!!  vedii"cd  to  live  pints.      Strain  and  m --\- 

as  a  beverage. 

UAKI.l.  Y     ■  AUK. 

Tut  iii  a  iQuee-pan  r  pints  water,  2  os.  pearl  barley;  stir  bow 
and  then  when  boiling;  add  2  oz.  white  Bugar,  tin-  rind  <>t'  half 
a   lemon   thinly  peeled;   boil  genfly  for  two  bohrs,  and  serve 

either  -trained  or  willi  the  barley  K  It  in. 

( 'IMMi:  \\      I.KMONADI'. 

Tut  in  a  basin  '1  table-spoonfuls  of  white,  or  brown  sugar,  \  a 

table-spoonful  lime  juice;  mix  well  together,  anil  add  one  pint 
of  water. 

CITRIC    ACID     I.I   Mi'N  U>K. 

Dissolve  1  oz.  citric  acid  in  1  pint  of  cold  water  :  add  1  lb.  !• 
oz.  white  soger;  mix  well  bo  lorn,  a  thick  syrup;  then  put  in  lit 
pints  cold  water,  slowly  mixing  well. 

TOAST    AM)    WATEK. 

Cut  a  piece  of  crusty  bread,  about  |  lb.:  toast  gently  and  oni- 

tbrmly  to  a  lijrht  yellow  color:  then  piece  near  the  lire,  and 
when  of  a  good  brown  chocolate  put    in  a  pitcher;    pour  on  it  .'! 

jj  its  boiling  water;  cover  the  pitcher,  and,  when  cold,  strain. 
it  is  then  read}  for  use.  Never  have  the  toast  in,  as  it  causes 
fermentation  in  a  short  time. 

A  piece  of  apple,  slowly  toasted  till  it  gets  quite  black,  and 
added  to  the  above,  makes  a  wry  refreshing  drink. 


